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IRWIN-POTTER PHARMACY LLC
CAH171331-00 KIOWA DISTRICT HOSPITAL
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Covered Entity Details
Entity Name
KIOWA DISTRICT HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171331-00
Entity Address
1002 South 4th Street
KIOWA, KS 67070-0184
Medicare Provider Number
171331
Participating Start Date
7/1/2015
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
IRWIN-POTTER PHARMACY LLC
Pharmacy Address
D/B/A IRWIN-POTTER DRUG
202 W MAIN ST
ANTHONY, KS 67003
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
12/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Janell L Goodno, CFO
(620) 825-4131 Ext: 1001
Contract Pharmacy Representative
Freeman Pharmacy
Lance Freeman, Mgr
(620) 842-5119
Signed By Date
4/16/2018
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