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STORMONT-VAIL RETAIL PHARMACY
DSH170086 STORMONT-VAIL HEALTHCARE INC.
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Covered Entity Details
Entity Name
STORMONT-VAIL HEALTHCARE INC.
Subdivision Name
DBA STORMONT VAIL HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH170086
Entity Address
1500 SW 10TH AVE
TOPEKA, KS 66604
Medicare Provider Number
170086
Participating Start Date
4/1/2018
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
STORMONT-VAIL RETAIL PHARMACY
Pharmacy Address
2252 SW 10TH AVE
TOPEKA, KS 66604-3965
Pharmacy Comments
08/15/2012 name change (was Stormont-Vail, Inc. dba Medical Arts Pharmacy)
Contract Details
Approval Date
6/6/2012
Contract Begin Date
6/6/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Maynard F. Oliverius, President and CEO
(785) 354-6121
Contract Pharmacy Representative
Carol Wheeler, President
(785) 354-6115
Signed By Date
5/21/2012
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