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WAL-MART PHARMACY 10-0178
CAH171331-00 KIOWA DISTRICT HOSPITAL
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Covered Entity Details
Entity Name
KIOWA DISTRICT HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171331-00
Entity Address
1002 South 4th Street
KIOWA, KS 67070-0184
Medicare Provider Number
171331
Participating Start Date
7/1/2015
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0178
Pharmacy Address
914 EAST OKLAHOMA BLVD.
ALVA, OK 73717
Pharmacy Comments
Contract Details
Approval Date
10/12/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Janell L Goodno, CFO
(620) 825-4131 Ext: 1001
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/12/2020
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