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POWELL DRUG
CAH531310-00 Powell Valley Healthcare
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Covered Entity Details
Entity Name
Powell Valley Healthcare
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH531310-00
Entity Address
777 Ave H
Powell, WY 82435
Medicare Provider Number
531310
Participating Start Date
1/1/2012
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
POWELL DRUG
Pharmacy Address
140 N BENT ST
POWELL, WY 82435
Pharmacy Comments
Contract Details
Approval Date
10/12/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Ownership change
Contacts
Covered Entity Signing Official
Terry Odom, CEO
(307) 754-1101
Contract Pharmacy Representative
PHARMACISTS IMPROVING LIVES, INC. DBA Powell Drug
David W. Klingler, Owner
(307) 754-2031
Signed By Date
10/12/2018
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