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SHOPKO PHARMACY #2656
CAH231301-00 KALKASKA MEMORIAL HEALTH CENTER
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Covered Entity Details
Entity Name
KALKASKA MEMORIAL HEALTH CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231301-00
Entity Address
419 S. CORAL ST.
KALKASKA, MI 49646
Medicare Provider Number
231301
Participating Start Date
8/31/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2656
Pharmacy Address
784 S CEDAR ST
KALKASKA, MI 49646
Pharmacy Comments
Contract Details
Approval Date
7/15/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/27/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Kevin Rogols, CEO
(231) 258-7501
Contract Pharmacy Representative
ShopKo
Lorie Neumann, Contracting & Compliance
(920) 429-4726
Signed By Date
7/15/2016
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