Contract Pharmacy Details

CANEY DRUG
DSH170145 COFFEYVILLE REG MEDICAL CENTER INC.

Covered Entity Details

Entity Name

COFFEYVILLE REG MEDICAL CENTER INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH170145

Entity Address

1400 WEST 4TH STREET
COFFEYVILLE, KS 67337

Medicare Provider Number

170145

Participating Start Date

5/25/2022

Last Recertification Date

8/31/2023

Entity Termination Date

5/13/2024

Pharmacy Details

Pharmacy Name

CANEY DRUG

Pharmacy Address

208 W. 4TH
CANEY, KS 67333

Pharmacy Comments

Contract Details

Approval Date

6/1/2022

Contract Begin Date

6/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

5/13/2024
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Brian Heath Lawrence, CEO
(620) 252-1519

Contract Pharmacy Representative

Caney Drug
Gavin Duley, President
(620) 879-5822

Signed By Date

6/1/2022