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STONER DRUG
CAH161366-01 Shenandoah Medical Center
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Covered Entity Details
Entity Name
Shenandoah Medical Center
Subdivision Name
SHENANDOAH MEDICAL CENTER - Shenandoah Physicians Clinic - Sidney (Primary Care Clinic)
Type
Critical Access Hospital
340B ID
CAH161366-01
Entity Address
802 ILLINOIS ST
FREMONT COUNTY MEDICAL CENTER
SIDNEY, IA 51652-8028
Medicare Provider Number
161366
Outpatient Facility Provider Number
168569
Participating Start Date
10/1/2018
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
STONER DRUG
Pharmacy Address
712 MAIN ST
TABOR, IA 51653-2067
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matthew Richard Sells, President and CEO
(712) 246-7160
Contract Pharmacy Representative
Stoner Drug
Angela Alley, Pharmacist
(712) 629-2945
Signed By Date
7/14/2020
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