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KEYSTONE DRUG
CAH271314-00 Powell County Memorial Hospital Association, Inc. DBA Deer Lodge Medical Center
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Covered Entity Details
Entity Name
Powell County Memorial Hospital Association, Inc. DBA Deer Lodge Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH271314-00
Entity Address
1100 Hollenbeck Ln
Deer Lodge, MT 59722
Medicare Provider Number
271314
Participating Start Date
10/1/2011
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
KEYSTONE DRUG
Pharmacy Address
ATTN: JACK M. ANDERSEN, PHARMACIST IN CH
407 MAIN STREET
DEER LODGE, MT 59722
Pharmacy Comments
Contract Details
Approval Date
12/3/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2021
Ownership change
Contacts
Covered Entity Signing Official
Tony Pfaff, CEO
(406) 846-2212 Ext: 111
Contract Pharmacy Representative
Jack Andersen, Owner
(406) 846-2120
Signed By Date
10/29/2012
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