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AUBURN PHARMACY
CAH171385-04 Coffey County Hospital
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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
AUBURN PHARMACY
Pharmacy Address
890 LAKIN ST
OSAGE CITY, KS 66523-1152
Pharmacy Comments
Contract Details
Approval Date
4/10/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Leonard Ray Hernandez, CEO
(620) 364-4570
Contract Pharmacy Representative
AuBurn Pharmacy 171
Ryan Moore, VP Operations
(785) 448-3600
Signed By Date
4/10/2018
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