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GIBSON HEALTH MART
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
GIBSON HEALTH MART
Pharmacy Address
GIBSON DRUG, INC.
125 N. MAIN ST
WAKEENEY, KS 67672
Pharmacy Comments
Contract Details
Approval Date
7/15/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DAVID AUGUSTINE, CEO
(785) 743-2182 Ext: 175
Contract Pharmacy Representative
Bernita Augustine, Owner
(785) 743-5753
Signed By Date
7/15/2014
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