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WAL-MART 10-5441
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
WAL-MART 10-5441
Pharmacy Address
2600 NW ROCHESTER RD
TOPEKA, KS 66617
Pharmacy Comments
Contract Details
Approval Date
4/2/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/12/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JOHN MOORE, CEO/ADMINISTRATOR
(785) 742-2131 Ext: 283
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/2/2015
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