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DILLONS PHARMACY #5
HV00142A UKSM-W MEDICAL PRACTICE ASSOCIATION
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Covered Entity Details
Entity Name
UKSM-W MEDICAL PRACTICE ASSOCIATION
Subdivision Name
Type
Ryan White Part C
340B ID
HV00142A
Entity Address
712 A St John Street
Garden City, KS 67846
Grant Number
H76HA00142
Participating Start Date
4/1/2020
Last Recertification Date
2/7/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
DILLONS PHARMACY #5
Pharmacy Address
1305 E KANSAS AVE
GARDEN CITY, KS 67846
Pharmacy Comments
Contract Details
Approval Date
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Aaron Ryan, ADMINISTRATOR
(316) 293-3526
Contract Pharmacy Representative
Kroger Health
Eva Brumfield, Strategic Program Director
(651) 357-2109
Signed By Date
7/15/2024
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