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STORMONT-VAIL RETAIL PHARMACY
DSH170086 STORMONT-VAIL HEALTHCARE INC.
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Covered Entity Details
Entity Name
STORMONT-VAIL HEALTHCARE INC.
Subdivision Name
DBA STORMONT VAIL HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH170086
Entity Address
1500 SW 10TH AVE
TOPEKA, KS 66604
Medicare Provider Number
170086
Participating Start Date
4/1/2018
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
STORMONT-VAIL RETAIL PHARMACY
Pharmacy Address
2252 SW 10TH AVE
TOPEKA, KS 66604-3965
Pharmacy Comments
08/15/2012 name change (was Stormont-Vail, Inc. dba Medical Arts Pharmacy)
Contract Details
Approval Date
4/10/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/4/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Robert Odin Langland, Sr VP Finance
(785) 354-6148
Contract Pharmacy Representative
Stormont Vail Health
Vicki Merillat, 340B Pharmacy Buyer
(785) 354-6867
Signed By Date
4/10/2018
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