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DILLON PHARMACY
SCH170027-00 PRATT REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
PRATT REGIONAL MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH170027-00
Entity Address
200 - 300 COMMODORE
PRATT, KS 67124
Medicare Provider Number
170027
Participating Start Date
10/1/2015
Last Recertification Date
8/20/2016
Entity Termination Date
1/1/2018
Pharmacy Details
Pharmacy Name
DILLON PHARMACY
Pharmacy Address
1108 E FIRST STREET
PRATT, KS 67124
Pharmacy Comments
Contract Details
Approval Date
10/15/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Vincent S. Wilczek, CFO
(620) 450-1436
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
10/15/2015
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