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TICE HEALTH MART
CAH171341-00 Hiawatha Hospital Association, Inc
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Covered Entity Details
Entity Name
Hiawatha Hospital Association, Inc
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171341-00
Entity Address
300 UTAH ST.
HIAWATHA, KS 66434-2399
Medicare Provider Number
171341
Participating Start Date
4/1/2011
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
TICE HEALTH MART
Pharmacy Address
618 OREGON ST
HIAWATHA, KS 66434-2231
Pharmacy Comments
Contract Details
Approval Date
2/1/2012
Contract Begin Date
2/1/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
JOHN MOORE, CEO/ADMINISTRATOR
(785) 742-2131 Ext: 283
Contract Pharmacy Representative
Leland Hansen, Pharmacist/Owner
(785) 742-2191
Signed By Date
1/24/2012
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