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VICKLUND INC
CAH531304-02 HOT SPRINGS COUNTY MEMORIAL
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Covered Entity Details
Entity Name
HOT SPRINGS COUNTY MEMORIAL
Subdivision Name
Red Rock Family Practice - Rural Health Clinic
Type
Critical Access Hospital
340B ID
CAH531304-02
Entity Address
120 N C Ave
Thermopolis, WY 82443-2410
Medicare Provider Number
531304
Outpatient Facility Provider Number
533996
Participating Start Date
4/1/2019
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
VICKLUND INC
Pharmacy Address
DBA HOT SPRINGS PHARMACY
610 S 6TH ST
THERMOPOLIS, WY 82443
Pharmacy Comments
Contract Details
Approval Date
4/11/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Margie Renee Pecks-Molitor, CEO
(307) 864-5034
Contract Pharmacy Representative
Vicklund Pharmacy
Anthony Deromedi, President/Owener
(307) 864-2369
Signed By Date
4/11/2019
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