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SHOPKO PHARMACY #2705
CAH261309-00 Saint Luke's Hospital of Trenton DBA WRIGHT MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
Saint Luke's Hospital of Trenton DBA WRIGHT MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261309-00
Entity Address
191 IOWA BLVD
TRENTON, MO 64683
Medicare Provider Number
261309
Participating Start Date
9/9/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2705
Pharmacy Address
2001 E 9TH ST
TRENTON, MO 64683
Pharmacy Comments
Contract Details
Approval Date
10/12/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/4/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gary Jordan, CEO
(660) 358-5701
Contract Pharmacy Representative
ShopKo
Lorie Neumann, Contracting & Compliance
(920) 429-4726
Signed By Date
10/12/2015
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