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WAL-MART PHARMACY 10-0664
CAH171355-02 Trego County Lemke Memorial Hospital
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Covered Entity Details
Entity Name
Trego County Lemke Memorial Hospital
Subdivision Name
Ellis Family Care Center
Type
Critical Access Hospital
340B ID
CAH171355-02
Entity Address
1000 Washington Street
Ellis, KS 67637
Medicare Provider Number
171355
Outpatient Facility Provider Number
178538
Participating Start Date
4/1/2014
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0664
Pharmacy Address
4301 VINE STREET
HAYS, KS 67601
Pharmacy Comments
Contract Details
Approval Date
4/2/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DAVID AUGUSTINE, CEO
(785) 743-2182 Ext: 175
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/2/2014
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