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THE KROGER CO., KS 113
CAH171301-00 GREAT PLAINS OF ELLINWOOD INC.
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Covered Entity Details
Entity Name
GREAT PLAINS OF ELLINWOOD INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171301-00
Entity Address
300 N Park
ELLINWOOD, KS 67526
Medicare Provider Number
171301
Participating Start Date
1/1/2018
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
THE KROGER CO., KS 113
Pharmacy Address
1220 S. LIPAN STREET
DENVER, CO 80223
Pharmacy Comments
Contract Details
Approval Date
10/9/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/20/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kile Neal Magner, CEO
(620) 564-2548
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/9/2019
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