Contract Pharmacy Details

GREYBULL DRUG, LLC
CAH531301-00 SOUTH BIG HORN HOSPITAL

Covered Entity Details

Entity Name

SOUTH BIG HORN HOSPITAL

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH531301-00

Entity Address

388 HWY 20 SOUTH
BASIN, WY 82410

Medicare Provider Number

531301

Participating Start Date

10/1/2017

Last Recertification Date

8/16/2023

Entity Termination Date

10/1/2024

Pharmacy Details

Pharmacy Name

GREYBULL DRUG, LLC

Pharmacy Address

925 N. 6TH ST
GREYBULL, WY 82426

Pharmacy Comments

Contract Details

Approval Date

1/24/2022

Contract Begin Date

4/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2024
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Ricky Alan Schroeder, Interim CEO
(307) 568-3311

Contract Pharmacy Representative

greybull drug
Ross Davidson, PIC
(307) 765-4601

Signed By Date

1/24/2022