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SHOPKO PHARMACY #2764
CAH531308-00 JOHNSON COUNTY HEALTHCARE
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Covered Entity Details
Entity Name
JOHNSON COUNTY HEALTHCARE
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH531308-00
Entity Address
497 W LOTT St
BUFFALO, WY 82834
Medicare Provider Number
531308
Participating Start Date
7/1/2018
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2764
Pharmacy Address
129 HARMONY STREET
BUFFALO, WY 82834
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/10/2018
Agreement registered in error
Contacts
Covered Entity Signing Official
Nicole Ann Hobbs, CEO
(307) 684-6188
Contract Pharmacy Representative
Shopko Pharmacy
Debi Danbury, 340B Program Manager
(920) 429-7613
Signed By Date
4/16/2018
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