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MEDICINE SHOPPE #1153
DSH170145 COFFEYVILLE REG MEDICAL CENTER INC.
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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
MEDICINE SHOPPE #1153
Pharmacy Address
SAINT-MARK ENTERPRISES LLC
1001 W. 11TH ST
COFFEYVILLE, KS 67337-4220
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
St Mark Enterprises
Rik St. Germain, Owner
(206) 650-5541
Signed By Date
6/1/2022
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