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KANSAS CVS PHARMACY, L.L.C.
DSH170122 Ascension Via Christi Hospitals Wichita, Inc
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Covered Entity Details
Entity Name
Ascension Via Christi Hospitals Wichita, Inc
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH170122
Entity Address
929 N. St. Francis
Wichita, KS 67214
Medicare Provider Number
170122
Participating Start Date
1/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
KANSAS CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #10159
2014 WEST 21ST AVE N
WICHITA, KS 67203
Pharmacy Comments
Contract Details
Approval Date
1/14/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jim C Garrelts, Vice President, Pharmacy
(316) 268-5580
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/14/2022
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