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DSH170145 COFFEYVILLE REG MEDICAL CENTER INC. (Terminated)
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Main Details
Name
COFFEYVILLE REG MEDICAL CENTER INC.
Subdivision Name
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH170145
Medicare Provider Number
170145
Additional Details
Current Program Status
Terminated
Registration Date
5/20/2022
Participating Start Date
5/25/2022
Participating Approval Date
5/25/2022
Last Recertification Date
8/31/2023
Termination Date
Termination Reason
5/13/2024
Other
Contacts
Authorizing Official
Coffeyville Regional Medical Center
Brian Heath Lawrence, CEO
(620) 252-1519
Primary Contact
Coffeyville Regional Medical Center
Stephen Haley, Director of Pharmacy
(620) 252-1695
Addresses
Street Address
1400 WEST 4TH STREET
COFFEYVILLE, KS 67337
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating start 10/1/2016, Termination 10/1/2018, Reinstatement 5/25/2022
05/25/2022
April 2025
April 2025
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