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ELMWOOD PHARMACY
RWIID685091 NEBRASKA DEPT OF HEALTH & HUMAN SERVICES
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Covered Entity Details
Entity Name
NEBRASKA DEPT OF HEALTH & HUMAN SERVICES
Subdivision Name
DIVISION OF SERVICES
Type
Ryan White Part B ADAP Direct Purchase
340B ID
RWIID685091
Entity Address
301 CENTENNIAL MALL S., 3RD FL
LINCOLN, NE 68509-5026
Grant Number
X07HA00042
Participating Start Date
4/1/1997
Last Recertification Date
2/5/2021
Entity Termination Date
7/1/2021
Pharmacy Details
Pharmacy Name
ELMWOOD PHARMACY
Pharmacy Address
KILBORNS INC. DBA ELMWOOD PHARMACY
5203 LEAVENWORTH ST
OMAHA, NE 68106
Pharmacy Comments
Contract Details
Approval Date
10/13/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
STEPHEN G JACKSON, RYAN WHITE PROGRAM MANAGER
(402) 471-2504
Contract Pharmacy Representative
Elmwood Pharmacy
Jeffrey Kilborn, President
(402) 551-5200
Signed By Date
10/13/2016
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