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EXPRESS SCRIPTS PHARMACY, INC.
CAH031300-00 WICKENBURG COMMUNITY HOSPITAL ASSOCIATION INC
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Covered Entity Details
Entity Name
WICKENBURG COMMUNITY HOSPITAL ASSOCIATION INC
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031300-00
Entity Address
520 ROSE LANE
WICKENBURG, AZ 85390
Medicare Provider Number
031300
Participating Start Date
4/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
EXPRESS SCRIPTS PHARMACY, INC.
Pharmacy Address
DBA EXPRESS SCRIPTS
255 PHILLIPI ROAD
COLUMBUS, OH 43228
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
JIM TAVARY, C.E.O.
(928) 684-4362
Contract Pharmacy Representative
Accredo Health Group
Gene McCabe, 340B Sales Director
(615) 943-7500
Signed By Date
4/16/2018
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