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WAL-MART PHARMACY 10-3596
CAH321301-00 SOCORRO GENERAL HOSPITAL
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Covered Entity Details
Entity Name
SOCORRO GENERAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH321301-00
Entity Address
1202 HIGHWAY 60 WEST
SOCORRO, NM 87801
Medicare Provider Number
321301
Participating Start Date
1/1/2017
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3596
Pharmacy Address
2250 MAIN STREET NW
LOS LUNAS, NM 87031
Pharmacy Comments
Contract Details
Approval Date
11/1/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DALE MAXWELL, SENIOR VP & CFO
(505) 923-5353
Contract Pharmacy Representative
Robert Love, Data Analyst
(908) 642-8060
Signed By Date
11/1/2016
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