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WAL-MART PHARMACY 10-0558
CAH171327-00 ELLSWORTH COUNTY MEDICAL CENTER
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Covered Entity Details
Entity Name
ELLSWORTH COUNTY MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171327-00
Entity Address
1604 AYLWARD AVE.
ELLSWORTH, KS 67439
Medicare Provider Number
171327
Participating Start Date
8/6/2010
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0558
Pharmacy Address
2900 SOUTH 9TH STREET
SALINA, KS 67401
Pharmacy Comments
Contract Details
Approval Date
1/7/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/12/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ROGER Alcide MASSE, CEO
(785) 472-5028 Ext: 315
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/7/2015
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