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UNIV HOSP OUTPATIENT PHARMACY
DSH320089 UNM SANDOVAL REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
UNM SANDOVAL REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320089
Entity Address
3001 BROADMOOR BLVD NE
RIO RANCHO, NM 87144
Medicare Provider Number
320089
Participating Start Date
4/1/2016
Last Recertification Date
8/17/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
UNIV HOSP OUTPATIENT PHARMACY
Pharmacy Address
1209 UNIVERSITY BLVD NE
ALBUQUERQUE, NM 87102
Pharmacy Comments
Contract Details
Approval Date
4/13/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Contacts
Covered Entity Signing Official
Jamie Silva-Steele, President and CEO
(505) 994-7430
Contract Pharmacy Representative
Monica Medina, Pharmacy Coordinator
(505) 272-2134
Signed By Date
4/13/2015
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