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DILLONS PHARMACY #33
HV073980 UKSM-W MEDICAL PRACTICE ASSOCIATION
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Covered Entity Details
Entity Name
UKSM-W MEDICAL PRACTICE ASSOCIATION
Subdivision Name
Type
Ryan White Part C
340B ID
HV073980
Entity Address
1010 N. KANSAS
WICHITA, KS 67214
Grant Number
H76HA00142
Participating Start Date
1/1/2003
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
DILLONS PHARMACY #33
Pharmacy Address
4747 SOUTH BROADWAY
WICHITA, KS 67216
Pharmacy Comments
Contract Details
Approval Date
4/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Aaron Ryan, ADMINISTRATOR
(316) 293-3526
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
4/15/2020
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