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WAL-MART PHARMACY 10-1187
CAH171385-00 Coffey County Hospital
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Covered Entity Details
Entity Name
Coffey County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171385-00
Entity Address
801 North Fourth
Burlington, KS 66839
Medicare Provider Number
171385
Participating Start Date
4/1/2018
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1187
Pharmacy Address
2200 N. STATE ST.
IOLA, KS 66749
Pharmacy Comments
Contract Details
Approval Date
1/16/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Leonard Ray Hernandez, CEO
(620) 364-4570
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/16/2019
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