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VICKLUND INC
CAH531304-00 HOT SPRINGS COUNTY MEMORIAL
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Covered Entity Details
Entity Name
HOT SPRINGS COUNTY MEMORIAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH531304-00
Entity Address
150 EAST ARAPAHOE
THERMOPOLIS, WY 82443
Medicare Provider Number
531304
Participating Start Date
10/1/2017
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
VICKLUND INC
Pharmacy Address
DBA HOT SPRINGS PHARMACY
610 S 6TH ST
THERMOPOLIS, WY 82443
Pharmacy Comments
Contract Details
Approval Date
10/13/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shelly Larson, CFO
(307) 864-5019
Contract Pharmacy Representative
Vicklund Pharmacy
Anthony Deromedi, President/Owener
(307) 864-2369
Signed By Date
10/13/2017
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