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SHOPKO PHARMACY #2772
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
SHOPKO PHARMACY #2772
Pharmacy Address
1005 W COULTER AVENUE
POWELL, WY 82435
Pharmacy Comments
Contract Details
Approval Date
7/13/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Terry Odom, CEO
(307) 754-1101
Contract Pharmacy Representative
ShopKo
Lorie Neumann, Contracting & Compliance
(920) 429-4726
Signed By Date
7/13/2016
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