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POWELL DRUG, INC.
CAH531310-00 Powell Valley Healthcare
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Covered Entity Details
Entity Name
Powell Valley Healthcare
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH531310-00
Entity Address
777 Ave H
Powell, WY 82435
Medicare Provider Number
531310
Participating Start Date
1/1/2012
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
POWELL DRUG, INC.
Pharmacy Address
140 N BENT PO BOX 191
POWELL, WY 82435-0191
Pharmacy Comments
Contract Details
Approval Date
3/2/2012
Contract Begin Date
3/2/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2018
Ownership change
Contacts
Covered Entity Signing Official
Mike Lieb, Interim CEO
(307) 754-1101
Contract Pharmacy Representative
Steve Rogers, President
(307) 754-2031
Signed By Date
2/29/2012
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