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GOTHENBURG DISCOUNT PHARM INC
CAH281313-00 Gothenburg Memorial Hospital
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Covered Entity Details
Entity Name
Gothenburg Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH281313-00
Entity Address
910 20th Street
Gothenburg, NE 69138
Medicare Provider Number
281313
Participating Start Date
1/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
GOTHENBURG DISCOUNT PHARM INC
Pharmacy Address
902 AVENUE D
GOTHENBURG, NE 69138
Pharmacy Comments
Contract Details
Approval Date
1/8/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Brant, CEO
(308) 537-3661
Contract Pharmacy Representative
Rick Zarek, President
(308) 537-7155
Signed By Date
1/8/2014
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