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MIDWEST FAMILY HEALTH OF RUSSELL, LLC
CAH171377-00 Great Plains of Smith County, dba Smith County Memorial Hospital
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Covered Entity Details
Entity Name
Great Plains of Smith County, dba Smith County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171377-00
Entity Address
921 E. Highway 36
Smith Center, KS 66967
Medicare Provider Number
171377
Participating Start Date
7/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
MIDWEST FAMILY HEALTH OF RUSSELL, LLC
Pharmacy Address
208 S FOSSIL ST
RUSSELL, KS 67665-3021
Pharmacy Comments
Contract Details
Approval Date
7/7/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Allen Van Driel, Chief Executive Officer
(785) 282-6845
Contract Pharmacy Representative
Robert Wenzl, Owner
(785) 543-5131
Signed By Date
7/7/2014
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