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DICKS PHARMACY
CAH141301-00 Kirby Medical Center
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Covered Entity Details
Entity Name
Kirby Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141301-00
Entity Address
1000 Medical Center Drive
Monticello, IL 61856
Medicare Provider Number
141301
Participating Start Date
4/1/2013
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
DICKS PHARMACY
Pharmacy Address
WOOD, BRUCE DENE
118 S. VINE
ARTHUR, IL 61911
Pharmacy Comments
Contract Details
Approval Date
1/12/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steven D. Tenhouse, Chief Executive Officer
(217) 762-2115 Ext: 1501
Contract Pharmacy Representative
Dick's Pharmacy
Cindi Reed, Owner/PIC
(217) 543-2913
Signed By Date
1/12/2023
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