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THE MEDICINE SHOPPE
CAH171385-00 Coffey County Hospital
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Covered Entity Details
Entity Name
Coffey County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171385-00
Entity Address
801 North Fourth
Burlington, KS 66839
Medicare Provider Number
171385
Participating Start Date
4/1/2018
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
THE MEDICINE SHOPPE
Pharmacy Address
716 N 4TH ST
BURLINGTON, KS 66839-6683
Pharmacy Comments
Contract Details
Approval Date
1/17/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/13/2021
Ownership change
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
1/15/2018
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