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WAL-MART PHARMACY 10-0869
CAH061301-00 RIO GRANDE HOSPITAL
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Covered Entity Details
Entity Name
RIO GRANDE HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061301-00
Entity Address
310 COUNTY ROAD 14
DEL NORTE, CO 81132
Medicare Provider Number
061301
Participating Start Date
9/9/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0869
Pharmacy Address
3333 CLARK STREET
ALAMOSA, CO 81101
Pharmacy Comments
Contract Details
Approval Date
10/5/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ARLENE HARMS, CEO
(719) 657-4104
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/5/2017
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