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PALACE DRUG STORE INC
CAH171362-00 Citizens Medical Center, Inc.
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Covered Entity Details
Entity Name
Citizens Medical Center, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171362-00
Entity Address
100 E College Drive
Colby, KS 67701
Medicare Provider Number
171362
Participating Start Date
7/1/2013
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
PALACE DRUG STORE INC
Pharmacy Address
460 N FRANKLIN
COLBY, KS 67701
Pharmacy Comments
Contract Details
Approval Date
7/12/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Ownership change
Contacts
Covered Entity Signing Official
Kevan Trenkle, CEO
(785) 462-7511
Contract Pharmacy Representative
Randy Smith, President
(785) 460-7507
Signed By Date
7/12/2013
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