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WAL-MART PHARMACY 10-2893
SCH170145-00 COFFEYVILLE REG MEDICAL CENTER INC.
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Covered Entity Details
Entity Name
COFFEYVILLE REG MEDICAL CENTER INC.
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH170145-00
Entity Address
1400 WEST 4TH STREET
COFFEYVILLE, KS 67337
Medicare Provider Number
170145
Participating Start Date
1/1/2019
Last Recertification Date
8/19/2021
Entity Termination Date
5/25/2022
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2893
Pharmacy Address
121 SO. PETER PAN ROAD
INDEPENDENCE, KS 67301
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lori Rexwinkle, Chief Executive Officer
(620) 252-1519
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/14/2019
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