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IOLA PHARMACY
CAH171385-01 Coffey County Hospital
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Covered Entity Details
Entity Name
Coffey County Hospital
Subdivision Name
WAVERLY MEDICAL CLINIC - PRIMARY CARE
Type
Critical Access Hospital
340B ID
CAH171385-01
Entity Address
302 PEARSON
WAVERLY, KS 66781
Medicare Provider Number
171385
Outpatient Facility Provider Number
173983
Participating Start Date
4/1/2018
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
IOLA PHARMACY
Pharmacy Address
109 E MADISON AVE
IOLA, KS 66749-3330
Pharmacy Comments
Contract Details
Approval Date
1/3/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Leonard Ray Hernandez, CEO
(620) 364-4570
Contract Pharmacy Representative
Iola Pharmacy
Travis Coffield, Partner
(620) 365-3176
Signed By Date
1/3/2020
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