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LOVELL DRUG
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
LOVELL DRUG
Pharmacy Address
ATTN: BRENT B. REASCH, PERSON IN CHARGE
164 E MAIN ST
PO BOX 847
LOVELL, WY 82431
Pharmacy Comments
Contract Details
Approval Date
10/1/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/21/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Terry Odom, CEO
(307) 754-1101
Contract Pharmacy Representative
Brent Reasch, Owner
(307) 548-7231
Signed By Date
10/1/2015
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