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CLELAND PHARMACY, LLC
CAH171355-02 Trego County Lemke Memorial Hospital
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Covered Entity Details
Entity Name
Trego County Lemke Memorial Hospital
Subdivision Name
Ellis Family Care Center
Type
Critical Access Hospital
340B ID
CAH171355-02
Entity Address
1000 Washington Street
Ellis, KS 67637
Medicare Provider Number
171355
Outpatient Facility Provider Number
178538
Participating Start Date
4/1/2014
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
CLELAND PHARMACY, LLC
Pharmacy Address
202 S 1ST STREET
WAKEENEY, KS 67672
Pharmacy Comments
Contract Details
Approval Date
7/8/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/13/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
DAVID AUGUSTINE, CEO
(785) 743-2182 Ext: 175
Contract Pharmacy Representative
Cleland Pharmacy
Joslyn Stum, PIC
(785) 743-6321
Signed By Date
7/8/2019
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