Contract Pharmacy Details

WAL-MART PHARMACY 10-0026
DSH170133 SAINT LUKE'S CUSHING HOSPITAL

Covered Entity Details

Entity Name

SAINT LUKE'S CUSHING HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH170133

Entity Address

711 MARSHALL STREET
LEAVENWORTH, KS 66048

Medicare Provider Number

170133

Participating Start Date

10/1/2009

Last Recertification Date

12/5/2017

Entity Termination Date

7/1/2018

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-0026

Pharmacy Address

5000 10TH AVE
LEAVENWORTH, KS 66048

Pharmacy Comments

Contract Details

Approval Date

7/9/2014

Contract Begin Date

10/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

9/30/2015
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Adele Ducharme, CEO
(913) 684-1101

Contract Pharmacy Representative

Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719

Signed By Date

7/9/2014

340B Drug Pricing Program Database