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UPTOWN DRUG
SCH030055-00 Kingman Regional Medical Center
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Covered Entity Details
Entity Name
Kingman Regional Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH030055-00
Entity Address
3269 Stockton Hill Road
Kingman, AZ 86409
Medicare Provider Number
030055
Participating Start Date
7/1/2013
Last Recertification Date
9/11/2024
Pharmacy Details
Pharmacy Name
UPTOWN DRUG
Pharmacy Address
2820 E ANDY DEVINE
KINGMAN, AZ 86401
Pharmacy Comments
Contract Details
Approval Date
7/10/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tim Blanchard, CFO
(928) 681-8668
Contract Pharmacy Representative
Uptown Drug and Home Medical
Chris Proffit, Owner
(928) 753-2226
Signed By Date
7/1/2013
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