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MEDICINE SHOPPE #1153
SCH170145-00 COFFEYVILLE REG MEDICAL CENTER INC.
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Covered Entity Details
Entity Name
COFFEYVILLE REG MEDICAL CENTER INC.
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH170145-00
Entity Address
1400 WEST 4TH STREET
COFFEYVILLE, KS 67337
Medicare Provider Number
170145
Participating Start Date
1/1/2019
Last Recertification Date
8/19/2021
Entity Termination Date
5/25/2022
Pharmacy Details
Pharmacy Name
MEDICINE SHOPPE #1153
Pharmacy Address
SAINT-MARK ENTERPRISES LLC
1001 W. 11TH ST
COFFEYVILLE, KS 67337-4220
Pharmacy Comments
Contract Details
Approval Date
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Sarah Marie Hoy, Interim CEO
(620) 252-1521
Contract Pharmacy Representative
St Mark Enterprises
Rik St. Germain, Owner
(206) 650-5541
Signed By Date
1/14/2020
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