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AVELLA OF ST LOUIS
CAH171331-00 KIOWA DISTRICT HOSPITAL
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Covered Entity Details
Entity Name
KIOWA DISTRICT HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171331-00
Entity Address
1002 South 4th Street
KIOWA, KS 67070-0184
Medicare Provider Number
171331
Participating Start Date
7/1/2015
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
AVELLA OF ST LOUIS
Pharmacy Address
450 N NEW BALLAS RD STE 256
SAINT LOUIS, MO 63141-6836
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/10/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Janell Goodno, CFO
(620) 825-4131 Ext: 1001
Contract Pharmacy Representative
Avella
Tammy Sievert, 340B Implementation and Analytics Manager, Corportate
(602) 769-3073
Signed By Date
4/15/2016
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