Contract Pharmacy Details

THE MEDICINE SHOPPE
CAH171385-04 Coffey County Hospital

Covered Entity Details

Entity Name

Coffey County Hospital

Subdivision Name

LE ROY MEDICAL CLINIC - PRIMARY CARE

Type

Critical Access Hospital

340B ID

CAH171385-04

Entity Address

538 C STREET
LE ROY, KS 66857

Medicare Provider Number

171385

Outpatient Facility Provider Number

173984

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

340B Drug Pricing Program Database