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WALMART PHARMACY 10-4361
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
WALMART PHARMACY 10-4361
Pharmacy Address
1105 EAST 15TH STREET
ELLSWORTH, KS 67439
Pharmacy Comments
Contract Details
Approval Date
7/7/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/12/2017
Pharmacy closed
Contacts
Covered Entity Signing Official
ROGER Alcide MASSE, CEO
(785) 472-5028 Ext: 315
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/7/2015
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