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WALMART PHARMACY 10-7129
CAH281356-00 PERKINS COUNTY HEALTH SERVICES
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Covered Entity Details
Entity Name
PERKINS COUNTY HEALTH SERVICES
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH281356-00
Entity Address
900 Lincoln Avenue
GRANT, NE 69140
Medicare Provider Number
281356
Participating Start Date
10/1/2015
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-7129
Pharmacy Address
201 PONY EXPRESS LANE
OGALLALA, NE 69153
Pharmacy Comments
Contract Details
Approval Date
4/11/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Derick Lorentz, CFO
(308) 352-7228
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/11/2017
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