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ST JOHNS DRUG
CAH031315-00 WHITE MOUNTAIN REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
WHITE MOUNTAIN REGIONAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031315-00
Entity Address
118 SOUTH MOUNTAIN AVE
SPRINGERVILLE, AZ 85938
Medicare Provider Number
031315
Participating Start Date
4/1/2017
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
ST JOHNS DRUG
Pharmacy Address
1155 W. CLEVELAND
PO BOX 517
ST JOHNS, AZ 85936
Pharmacy Comments
Contract Details
Approval Date
4/11/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gregory J. Was, CEO
(928) 333-7145
Contract Pharmacy Representative
Western Drug
Fred Harper, President
(928) 337-2229
Signed By Date
4/11/2018
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