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406 RX PLLC, DBA KEYSTONE FAMILY PHARMAC
CAH271314-00 Powell County Memorial Hospital Association, Inc. DBA Deer Lodge Medical Center
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Covered Entity Details
Entity Name
Powell County Memorial Hospital Association, Inc. DBA Deer Lodge Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH271314-00
Entity Address
1100 Hollenbeck Ln
Deer Lodge, MT 59722
Medicare Provider Number
271314
Participating Start Date
10/1/2011
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
406 RX PLLC, DBA KEYSTONE FAMILY PHARMAC
Pharmacy Address
407 MAIN ST
DEER LODGE, MT 59722
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/31/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Tony Pfaff, CEO
(406) 846-2212 Ext: 111
Contract Pharmacy Representative
406RX PLLC DBA Keystone Family Pharmacy
Joshua Fisher, Owner/Member
(406) 846-2120
Signed By Date
4/15/2021
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