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THE MEDICINE SHOPPE
RRC170094-00 COFFEY COUNTY HOSPITAL
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Covered Entity Details
Entity Name
COFFEY COUNTY HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC170094-00
Entity Address
801 NORTH FOURTH
BURLINGTON, KS 66839
Medicare Provider Number
170094
Participating Start Date
7/1/2016
Last Recertification Date
8/31/2016
Entity Termination Date
1/1/2017
Pharmacy Details
Pharmacy Name
THE MEDICINE SHOPPE
Pharmacy Address
716 N 4TH ST
BURLINGTON, KS 66839-6683
Pharmacy Comments
Contract Details
Approval Date
7/1/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Leonard Ray Hernandez, CEO
(620) 364-4570
Contract Pharmacy Representative
Medicine Shoppe Pharmacy 1490
Philip Beyer, Pharmacist In Charge
(620) 364-3388
Signed By Date
7/1/2016
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