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WAL-MART PHARMACY 10-2562
CAH171310-00 GREAT PLAINS OF CHEYENNE COUNTY INC
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Covered Entity Details
Entity Name
GREAT PLAINS OF CHEYENNE COUNTY INC
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171310-00
Entity Address
210 W. FIRST STREET
ST. FRANCIS, KS 67756
Medicare Provider Number
171310
Participating Start Date
1/1/2019
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2562
Pharmacy Address
2160 COMMERCE ROAD
GOODLAND, KS 67735
Pharmacy Comments
Contract Details
Approval Date
1/20/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Leslie Lacy, Administrator
(785) 332-2104 Ext: 119
Contract Pharmacy Representative
Great Plains of Cheyenne County, Inc.
Leslie Lacy, Administrator
(785) 332-2104 Ext: 119
Signed By Date
1/20/2020
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