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WAL-MART CENTRAL FILL 10-2670
DSH320002 ST. VINCENT HOSPITAL
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Covered Entity Details
Entity Name
ST. VINCENT HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320002
Entity Address
455 ST. MICHAELS DRIVE
SANTA FE, NM 87505
Medicare Provider Number
320002
Participating Start Date
1/1/2014
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WAL-MART CENTRAL FILL 10-2670
Pharmacy Address
608 SPRING HILL DR # 3 SUITE 300
SPRING, TX 77386
Pharmacy Comments
Contract Details
Approval Date
10/9/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Patrick B. Carrier, President & CEO
(505) 913-5202
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/9/2017
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