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WAL-MART PHARMACY 10-2562
CAH061313-00 KIT CARSON COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
KIT CARSON COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061313-00
Entity Address
286 16TH STREET
BURLINGTON, CO 80807
Medicare Provider Number
061313
Participating Start Date
4/1/2019
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2562
Pharmacy Address
2160 COMMERCE ROAD
GOODLAND, KS 67735
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Corey Fedie, COO
(719) 346-4800
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/15/2019
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