Covered Entity Details

DSH260011 SSM HEALTH-ST. MARYS-JEFFERSON CITY (ToBeTerminated) - information as of 6/24/2025 12:01:31 AM

Main Details

Name

SSM HEALTH-ST. MARYS-JEFFERSON CITY

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH260011

Medicare Provider Number

260011

Additional Details

Current Program Status

ToBeTerminated

Registration Date

4/8/2022

Participating Start Date

7/1/2022

Participating Approval Date

4/18/2022

Last Recertification Date

9/1/2024

Termination Date
Termination Reason

7/1/2025
DSH percentage below statutory minimum

Contacts

Authorizing Official

- SSM ST ANTHONY HOSPITAL
Shasta Manuel, VP of Finance CFO
(405) 272-7282

Primary Contact

SSM Health
Nathan Przybysz, 340b Program Manager
(314) 989-2214

Addresses

Street Address

2505 Mission Drive
JEFFERSON CITY, MO 65109

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 1/25/2021, terminated 10/1/2021. Reinstated 7/1/2022.	04/18/2022

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
MO	010322600	1518065523

Shipping Addresses

Shipping Address 1

SSM Health Pharmacy
2505 Mission Drive
Suite 110
Jefferson City, MO 65109

Shipping Address 2

SSM Health Medication Purchasing
2201 W Badger Rd
Madison, WI 53713

Shipping Address 3

SSM HEALTH-ST. MARYS-JEFFERSON CITY
2505 Mission Drive
Jefferson City, MO 65109

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	07/14/2021	10/01/2021	07/15/2021	07/16/2021
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/14/2021	10/01/2021	10/01/2021	10/01/2021
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/14/2021	10/01/2021	10/01/2021	10/01/2021
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/14/2021	10/01/2021	10/01/2021	10/01/2021
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	07/01/2022	10/01/2022	12/31/2020	10/15/2024
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/14/2021	10/01/2021	10/01/2021	10/01/2021
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/14/2021	10/01/2021	10/01/2021	10/01/2021
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/14/2021	10/01/2021	10/01/2021	10/01/2021
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/01/2022	10/01/2022	01/01/2024	10/15/2024
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	24416 N. 19TH AVE.	ATTEN: TERI KINZLE	PHOENIX	AZ	85085-1877	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	AVELLA OF ST LOUIS	450 N NEW BALLAS RD STE 256		SAINT LOUIS	MO	63141-6836	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	04/10/2023	07/01/2023	09/30/2024	10/15/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	10/15/2024	01/01/2025	07/01/2025	06/05/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	10/15/2024	01/01/2025	07/01/2025	06/05/2025
Contract Detail	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	07/04/2022	10/01/2022	01/01/2023	01/01/2023
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	10/17/2022	01/01/2023	07/01/2025	06/05/2025
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	07/01/2022	10/01/2022	02/25/2022	07/11/2022
Contract Detail	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	04/10/2023	07/01/2023	09/30/2024	10/15/2024
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/14/2021	10/01/2021	10/01/2021	10/01/2021
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	GENOA HEALTHCARE LLC	1780 OLD HIGHWAY 50 EAST	SUITE 100B	UNION	MO	63084	04/15/2024	07/01/2024	07/01/2025	06/05/2025
Contract Detail	GENOA HEALTHCARE LLC	4140 CHERRY ST STE B		WINSTON SALEM	NC	27105	04/15/2024	07/01/2024	07/01/2025	06/05/2025
Contract Detail	GENOA HEALTHCARE LLC	19515 BRUNE PARKWAY		WARRENTON	MO	63383	07/11/2024	10/01/2024	07/01/2025	06/05/2025
Contract Detail	GENOA HEALTHCARE LLC	1032 CROSSWINDS COURT		WENTZVILLE	MO	63385	07/11/2024	10/01/2024	07/01/2025	06/05/2025
Contract Detail	GENOA HEALTHCARE LLC	102 COMPASS POINT DRIVE, STE A		SAINT CHARLES	MO	63301	07/11/2024	10/01/2024	07/01/2025	06/05/2025
Contract Detail	MISSOURI CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 4080	300 KESTREL LANE	LAKE OZARK	MO	65049	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	MISSOURI CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY #18087	1801 MISSOURI BLVD	JEFFERSON CITY	MO	65109	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	MISSOURI CVS PHARMACY, L.L.C.	CVS PHARMACY # 16228	735 W STADIUM BLVD	JEFFERSON CITY	MO	65109	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	MISSOURI CVS PHARMACY, L.L.C.	CVS PHARMACY # 16228	735 W STADIUM BLVD	JEFFERSON CITY	MO	65109	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	MISSOURI CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY #18087	1801 MISSOURI BLVD	JEFFERSON CITY	MO	65109	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	MISSOURI CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 4080	300 KESTREL LANE	LAKE OZARK	MO	65049	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	04/13/2021	07/01/2021	07/13/2021	07/14/2021
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	OPTUM FRONTIER THERAPIES, LLC	325 W ATHERTON RD	SUITE 1	FLINT	MI	48507-2601	07/11/2024	10/01/2024	07/01/2025	06/05/2025
Contract Detail	OPTUM INFUSION SERVICES 103, LLC	9204 BERGER RD.	STE. A	COLUMBIA	MD	21046-1729	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	OPTUM INFUSION SERVICES 301, LP	7512 NORTH BROADWAY EXT STE 308		OKLAHOMA CITY	OK	73116-9055	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM INFUSION SERVICES 301, LP	7512 NORTH BROADWAY EXT STE 308		OKLAHOMA CITY	OK	73116-9055	07/01/2022	10/01/2022	05/04/2023	05/06/2023
Contract Detail	OPTUM INFUSION SERVICES 302, LLC	8720 S 114TH ST STE 106		LA VISTA	NE	68128-5585	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM INFUSION SERVICES 302, LLC	8720 S 114TH ST STE 106		LA VISTA	NE	68128-5585	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	4000 CHEMICAL RD STE 100		PLYMOUTH MEETING	PA	19462	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	OPTUM INFUSION SERVICES 500, INC.	2685 PATTON RD		ROSEVILLE	MN	55113	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	OPTUM INFUSION SERVICES 501, INC.	1867 LACKLAND HILL PKWY		SAINT LOUIS	MO	63146	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	7167 E. KEMPER RD.		CINCINNATI	OH	45249	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	1819 ASTON AVE STE 104		CARLSBAD	CA	92008	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	10607 & 10611 AURORA AVE.		URBANDALE	IA	50322	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	OPTUM INFUSION SERVICES 553, LLC	6531 MERIDIEN DR	SUITE 113	RALEIGH	NC	27616	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	07/14/2021	10/01/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	07/14/2021	10/01/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	07/11/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	01/22/2024	04/01/2024	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/17/2022	01/01/2023	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	04/15/2024	07/01/2024	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	11142 RENNER BLVD		LENEXA	KS	66219	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	07/14/2021	10/01/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	07/14/2021	10/01/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 705, LLC	11142 RENNER BLVD		LENEXA	KS	66219	07/04/2022	10/01/2022	04/10/2023	04/11/2023
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	04/10/2023	07/01/2023	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	07/01/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	07/11/2024	10/01/2024	07/01/2025	06/05/2025
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	OPTUMRX	2858 LOKER AVE E STE 100		CARLSBAD	CA	92010-6608	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	OPTUMRX	2858 LOKER AVE E STE 100		CARLSBAD	CA	92010-6608	07/04/2022	10/01/2022	03/31/2023	04/04/2023
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/01/2022	10/01/2022	10/31/2022	10/31/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	01/25/2021	04/01/2021	10/01/2021	10/01/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	04/10/2023	07/01/2023	09/30/2024	10/15/2024
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/10/2023	07/01/2023	09/30/2024	10/15/2024
Contract Detail	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	04/10/2023	07/01/2023	09/30/2024	10/15/2024
Contract Detail	SSM HEALTH PHARMACY	310 INTEGRITY DR		MADISON	WI	53717-1416	10/17/2022	01/01/2023	07/01/2025	06/05/2025
Contract Detail	SSM HEALTH SPECIALTY PHARMACY	SSM HEALTH CARE ST. LOUIS - OWNER	3662 PARK AVE STE 155	SAINT LOUIS	MO	63110	07/10/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	SSM MEDICAL GROUP INC (SSM HEALTH PHARMA	711 VETERANS MEMORIAL PKWY STE 102		SAINT CHARLES	MO	63303-2106	10/17/2022	01/01/2023	07/01/2025	06/05/2025
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WAL-MART PHARMACY 10-0029	724 STADIUM WEST BLVD		JEFERSON CITY	MO	65109	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART PHARMACY 10-0029	724 STADIUM WEST BLVD		JEFERSON CITY	MO	65109	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WAL-MART PHARMACY 10-0044	1802 S BUSINESS HWY 54		ELDON	MO	65026	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART PHARMACY 10-0044	1802 S BUSINESS HWY 54		ELDON	MO	65026	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WAL-MART PHARMACY 10-0051	1701 NO BLUFF STREET		FULTON	MO	65251	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART PHARMACY 10-0051	1701 NO BLUFF STREET		FULTON	MO	65251	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WAL-MART PHARMACY 10-0089	94 CECIL ST		CAMDENTON	MO	65020	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART PHARMACY 10-0089	94 CECIL ST		CAMDENTON	MO	65020	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WAL-MART PHARMACY 10-0354	1888 HWY 28 EAST		OWENSVILLE	MO	65066	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART PHARMACY 10-0354	1888 HWY 28 EAST		OWENSVILLE	MO	65066	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WAL-MART PHARMACY 10-0357	1003 WEST NEWTON ST	PO BOX 12	VERSAILLES	MO	65084	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART PHARMACY 10-0357	1003 WEST NEWTON ST	PO BOX 12	VERSAILLES	MO	65084	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WAL-MART PHARMACY 10-0815	4252 HWY. 54		OSAGE BEACH	MO	65065	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART PHARMACY 10-0815	4252 HWY. 54		OSAGE BEACH	MO	65065	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WAL-MART PHARMACY 10-5477	401 SUPERCENTER DR.		JEFFERSON CITY	MO	65101	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART PHARMACY 10-5477	401 SUPERCENTER DR.		JEFFERSON CITY	MO	65101	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/25/2021	01/25/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WALGREEN CO	DBA: WALGREENS #10907	1410 N BLUFF ST	FULTON	MO	65251	10/17/2022	01/01/2023	07/01/2025	06/05/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09713	3740 W TRUMAN BLVD	JEFFERSON CITY	MO	65109-0537	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03017	2002 MISSOURI BLVD.	JEFFERSON CITY	MO	65109	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	WALGREEN CO.	LINN DRUG #15826	POWERED BY WALGREENS 304 E MAIN STREET	LINN	MO	65051	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01142	3938 OSAGE BEACH PKWY	OSAGE BEACH	MO	65065-2146	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12749	900 EASTLAND DRIVE	JEFFERSON CITY	MO	65101	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15311	115 N EUCLID AVE STE A	SAINT LOUIS	MO	63108	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15311	115 N EUCLID AVE STE A	SAINT LOUIS	MO	63108	07/04/2022	10/01/2022	10/31/2022	10/31/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09713	3740 W TRUMAN BLVD	JEFFERSON CITY	MO	65109-0537	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03017	2002 MISSOURI BLVD.	JEFFERSON CITY	MO	65109	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12749	900 EASTLAND DRIVE	JEFFERSON CITY	MO	65101	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01142	3938 OSAGE BEACH PKWY	OSAGE BEACH	MO	65065-2146	07/04/2022	10/01/2022	10/31/2022	10/31/2022
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16072	3537 BROADWAY BLVD	KANSAS CITY	MO	64111	10/17/2022	01/01/2023	07/01/2025	06/05/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05146	1000 CLUB VILLAGE DRIVE	COLUMBIA	MO	65203	10/17/2022	01/01/2023	07/01/2025	06/05/2025
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16552	628 N NEW BALLAS RD STE A	CREVE COEUR	MO	63141	10/17/2022	01/01/2023	07/01/2025	06/05/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07428	801 S LIMIT	SEDALIA	MO	65301-5248	10/17/2022	01/01/2023	07/01/2025	06/05/2025
Contract Detail	WALGREEN CO.	LINN DRUG #15826	POWERED BY WALGREENS 304 E MAIN STREET	LINN	MO	65051	10/17/2022	01/01/2023	07/01/2025	06/05/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12307	120 S BISHOP AVE	ROLLA	MO	65401-4215	10/17/2022	01/01/2023	07/01/2025	06/05/2025
Contract Detail	Walgreens Central Fill #21394	2601 Hughes Road	Suite 103	Liberty	MO	64068	10/11/2023	01/01/2024	07/01/2025	06/05/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/13/2021	07/01/2021	10/01/2021	10/01/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/04/2022	10/01/2022	07/01/2025	06/05/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	07/04/2022	10/01/2022	10/31/2022	10/31/2022
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/11/2023	01/01/2024	07/01/2025	06/05/2025
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/11/2023	01/01/2024	07/01/2025	06/05/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH260011A	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SSM Health Medical Group Family Medicine - Lake Ozark - Family Medicine	2265 Bagnell Dam Blvd	Lake Ozark	MO	Terminated
DSH260011B	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	St. Mary's Jefferson City - Radiation Oncology	1241 W. Stadium Drive	Jefferson City	MO	ToBeTerminated
DSH260011C	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	St. Mary's Jefferson City - Outpatient Oncology - Oncology	2505 Mission Drive	Jefferson City	MO	Terminated
DSH260011D	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SSM Health Medical Group - Wound Care - Wound Care	2505 Mission Drive	Jefferson City	MO	Terminated
DSH260011E	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SSM Health Medical Group - Versailles - Family Medicine	801 Kidwell Drive	Versailles	MO	Terminated
DSH260011F	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SSM Health Medical Group - Urgent Care	2511 W. Edgewood Dr	Jefferson City	MO	ToBeTerminated
DSH260011G	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	Outpatient Brief Treatment - Behavioral Health	2701 West Edgewood Dr	Jefferson City	MO	ToBeTerminated
DSH260011H	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SSM Health Medical Group - Tipton - Family Medicine	875 Hwy 5 South	Tipton	MO	ToBeTerminated
DSH260011J	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	Outpatient Behavioral Health Services - Geriatrics, Severe and Persistent Mental Illnesses	2701 West Edgewood Dr.	Jefferson City	MO	ToBeTerminated
DSH260011K	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SSM Health Medical Group Family Medicine - Belle - Family Medicine	100 Hwy 28	Belle	MO	ToBeTerminated
DSH260011L	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SMJMC Outpatient Treatment Center - Outpatient Treatment	2505 Mission Dr	Jefferson City	MO	ToBeTerminated
DSH260011M	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SMJMC Spine Clinic - Spine	2505 Mission Drive	Jefferson City	MO	ToBeTerminated
DSH260011N	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SMJMC Pain Clinic - Pain	2505 Mission Dr	Jefferson City	MO	ToBeTerminated
DSH260011P	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SMJMC Psych Health - Psychiatry	2505 Mission Dr	Jefferson City	MO	ToBeTerminated
DSH260011Q	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SMJMC Pulmonology - Pulmonology	2505 Mission Dr	Jefferson City	MO	ToBeTerminated
DSH260011R	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SMJMC MC - Family Medicine	2511 W Edgewood	Jefferson City	MO	ToBeTerminated
DSH260011S	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SMJMC General Surgery - General Surgery	2505 Mission Dr	Jefferson City	MO	ToBeTerminated
DSH260011T	Child	DSH	SSM HEALTH-ST. MARYS-JEFFERSON CITY	SMJMC Orthopedic Clinic - Orthopedics	2505 Mission Dr	Jefferson City	MO	ToBeTerminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/29/2025 12:00:00 AM	6/5/2025 10:01 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/5/2025 10:01 AM
Terminations	Termination Date	Update	Termination Request		7/1/2025 12:00:00 AM	6/5/2025 10:01 AM
Terminations	Termination Effective Date	Update	Termination Request		5/30/2025 12:00:00 AM	6/5/2025 10:01 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	6/5/2025 10:01 AM
Contacts	Primary Contact	Update	PC Change Request	Schmitt, Michelle Nicole VP Pharmacy Financial Operations SSM Health 6082946203	Przybysz, Nathan 340b Program Manager SSM Health 3149892214	5/20/2025 10:22 AM
Contacts	Primary Contact	Update	Profile Change Request	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082946203	Schmitt, Michelle Nicole VP Pharmacy Financial Operations SSM Health 6082946203	5/19/2025 2:43 PM
Details	Last Recertification Date	Update	Recertification	8/29/2023 3:11:39 PM	9/1/2024 7:59:17 AM	9/1/2024 7:59 AM
Contacts	Primary Contact	Update	Profile Change Request	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082846203	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082946203	5/7/2024 9:40 AM
Addresses	Shipping Address	Update	Change Request	SSM Health Medication Purchasing 2202 W Beltline Hwy Madison, WI 53713	SSM Health Medication Purchasing 2201 W Badger Rd Madison, WI 53713	10/11/2023 10:59 AM
Contacts	Primary Contact	Update	PC Change Request	Sharrow, Nicholas Director of 340B Operations SSM Health 6087075611	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082846203	9/19/2023 7:17 AM
Contacts	Authorizing Official	Update	Change Request	Rewerts, Karen D. Regional VP of Financa/CFO SSM Health 3149892034	Manuel, Shasta VP of Finance CFO - SSM ST ANTHONY HOSPITAL 4052727282	8/31/2023 9:51 AM
Details	Last Recertification Date	Update	Recertification	9/15/2022 8:18:05 AM	8/29/2023 3:11:39 PM	8/29/2023 3:11 PM
Contacts	Primary Contact	Update	Change Request	McAllister, Anita System Director of 340B Operations SSM Health 3149896778	Sharrow, Nicholas Director of 340B Operations SSM Health 6087075611	5/21/2023 8:23 AM
Addresses	Main Address	Update	Change Request	2505 Mission Drive JEFFERSON CITY, MO 65101	2505 Mission Drive JEFFERSON CITY, MO 65109	1/26/2023 7:10 AM
Contacts	Primary Contact	Update	Profile Change Request	McAllister, Anita System Director of 340B Operations SSM Health 9193576357	McAllister, Anita System Director of 340B Operations SSM Health 3149896778	1/10/2023 9:39 AM
Contacts	Primary Contact	Update	Group Change Request	Violette, Chelsea Director of Optimization Spendmend 8452066019	McAllister, Anita System Director of 340B Operations SSM Health 9193576357	12/1/2022 6:46 AM
Addresses	Main Address	Update	Change Request	2500 Mission Drive JEFFERSON CITY, MO 65101	2505 Mission Drive JEFFERSON CITY, MO 65101	11/22/2022 7:55 AM
Addresses	Main Address	Update	Change Request	100 ST. MARYS MEDICAL PLAZA JEFFERSON CITY, MO 65101	2500 Mission Drive JEFFERSON CITY, MO 65101	10/28/2022 3:34 PM
Contacts	Primary Contact	Update	Group Change Request	Sharrow, Nicholas Director of 340B Operations SSM Health 6087075611	Violette, Chelsea Director of Optimization Spendmend 8452066019	9/28/2022 9:57 AM
Details	Last Recertification Date	Update	Recertification		9/15/2022 8:18:05 AM	9/15/2022 8:18 AM
Contacts	Primary Contact	Update	Group Change Request	Coultrip, Susan 340B Program Director SSM of Oklahoma 4058123230	Sharrow, Nicholas Director of 340B Operations SSM Health 6087075611	8/22/2022 6:53 AM
Addresses	Shipping Address	Insert	Change Request		SSM HEALTH-ST. MARYS-JEFFERSON CITY 2505 Mission Drive Jefferson City, MO 65109	7/1/2022 6:17 AM
Details	State	Update		Approved	Active	7/1/2022 12:01 AM
Addresses	Billing Address	Insert	Change Request		SSM HEALTH-ST. MARYS-JEFFERSON CITY 2505 Mission Drive Jefferson City, MO 65109	6/24/2022 11:05 AM
Addresses	Billing Address	Update	Change Request	SSM Health St. Mary's Hospital - Jefferson City 2505 Mission Drive Jefferson City, MO 65109	SSM Health St. Mary's Hospital - Jefferson City 2202 W Beltline Hwy Madison, WI 53713	6/9/2022 8:22 AM
Addresses	Shipping Address	Insert	Change Request		SSM Health Medication Purchasing 2202 W Beltline Hwy Madison, WI 53713	6/9/2022 8:22 AM
Contacts	Authorizing Official	Update	Change Request	Miller, Becky Vice President-Hospital Operations SSM Health 5736813136	Rewerts, Karen D. Regional VP of Financa/CFO SSM Health 3149892034	5/12/2022 6:35 AM
Addresses	Billing Address	Insert	Reinstatement		SSM Health St. Mary's Hospital - Jefferson City 2505 Mission Drive Jefferson City, MO 65109	4/18/2022 1:56 PM
Contacts	Primary Contact	Update	Reinstatement	White, Tamika Senior Financial Analyst SSM Health 3149892320	Coultrip, Susan 340B Program Director SSM of Oklahoma 4058123230	4/18/2022 1:56 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	9/30/2021 12:00:00 AM		4/18/2022 1:56 PM
Dates	Participating Approval Date	Update	Reinstatement	1/25/2021 8:04:59 AM	4/18/2022 1:56:56 PM	4/18/2022 1:56 PM
Details	State	Update	Reinstatement	Terminated	Approved	4/18/2022 1:56 PM
Dates	Registration Date	Update	Reinstatement	1/13/2021 2:44:31 PM	4/8/2022 11:50:13 AM	4/18/2022 1:56 PM
Dates	Signed By Date	Update	Reinstatement	1/14/2021 11:53:14 AM	4/13/2022 12:07:57 PM	4/18/2022 1:56 PM
Dates	Start Date	Update	Reinstatement	1/25/2021 12:00:00 AM	7/1/2022 12:00:00 AM	4/18/2022 1:56 PM
Terminations	Termination Date	Update	Reinstatement	10/1/2021 12:00:00 AM		4/18/2022 1:56 PM
Terminations	Termination Effective Date	Update	Reinstatement	10/1/2021 12:00:00 AM		4/18/2022 1:56 PM
Terminations	Termination Reason	Update	Reinstatement	Failure to recertify		4/18/2022 1:56 PM
Details	Comments Public	Insert	Reinstatement		Participated starting 1/25/2021, terminated 10/1/2021. Reinstated 7/1/2022.	4/18/2022 12:43 PM
Details	State	Update		To Be Terminated	Terminated	10/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		9/30/2021 12:00:00 AM	9/17/2021 7:41 AM
Details	State	Update	Recertification	Active	To Be Terminated	9/17/2021 7:41 AM
Terminations	Termination Date	Update	Recertification		10/1/2021 12:00:00 AM	9/17/2021 7:41 AM
Terminations	Termination Effective Date	Update	Recertification		10/1/2021 12:00:00 AM	9/17/2021 7:41 AM
Terminations	Termination Reason	Update	Recertification		Failure to recertify	9/17/2021 7:41 AM
Contacts	Primary Contact	Update	Change Request	Peine, Jeffrey Finance Director SSM Health 3149893532	White, Tamika Senior Financial Analyst SSM Health 3149892320	7/7/2021 8:01 AM
Addresses	Shipping Address	Insert	Change Request		SSM Health Pharmacy 2505 Mission Drive Suite 110 Jefferson City, MO 65109	5/18/2021 10:33 AM
Details	State	Update	OPA Edit	Approved	Active	1/25/2021 8:13 AM
Dates	Start Date	Update	OPA Edit	4/1/2021 12:00:00 AM	1/25/2021 12:00:00 AM	1/25/2021 8:13 AM
Contacts	Signed By	Insert	New Registration		Miller, Becky Vice President-Hospital Operations SSM Health 5736813136	1/25/2021 8:04 AM
Details	340B ID	Update	New Registration		DSH260011	1/25/2021 8:04 AM
Dates	Participating Approval Date	Update	New Registration		1/25/2021 8:04:59 AM	1/25/2021 8:04 AM
Details	State	Update	New Registration	Pending	Approved	1/25/2021 8:04 AM
Dates	Signed By Date	Update	New Registration		1/14/2021 11:53:14 AM	1/25/2021 8:04 AM
Dates	Start Date	Update	New Registration		4/1/2021 12:00:00 AM	1/25/2021 8:04 AM
Addresses	Main Address	Insert	New Registration		100 ST. MARYS MEDICAL PLAZA JEFFERSON CITY, MO 65101	1/13/2021 2:44 PM
Addresses	Billing Address	Insert	New Registration		SSM Health St. Mary's Hospital - Jefferson City 2505 Mission Drive Jefferson City, MO 65109	1/13/2021 2:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2021 2:44 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010322600	1/13/2021 2:44 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/13/2021 2:44 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1518065523	1/13/2021 2:44 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/13/2021 2:44 PM
Contacts	Primary Contact	Insert	New Registration		Peine, Jeffrey Finance Director SSM Health 3149893532	1/13/2021 2:44 PM
Contacts	Authorizing Official	Insert	New Registration		Miller, Becky Vice President-Hospital Operations SSM Health 5736813136	1/13/2021 2:44 PM
Details	Assistance Received From Date	Insert	New Registration			1/13/2021 2:44 PM
Details	Assistance Received To Date	Insert	New Registration			1/13/2021 2:44 PM
Details	Last Recertification Date	Insert	New Registration			1/13/2021 2:44 PM
Details	Grant Number	Insert	New Registration			1/13/2021 2:44 PM
Details	340B ID	Insert	New Registration			1/13/2021 2:44 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/13/2021 2:44 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/13/2021 2:44 PM
Details	Medicare Provider Number	Insert	New Registration		260011	1/13/2021 2:44 PM
Details	Entity Name	Insert	New Registration		SSM HEALTH-ST. MARYS-JEFFERSON CITY	1/13/2021 2:44 PM
Details	NOFO Number	Insert	New Registration			1/13/2021 2:44 PM
Details	Program Code	Insert	New Registration		DSH	1/13/2021 2:44 PM
Details	Entity Subname	Insert	New Registration			1/13/2021 2:44 PM
Dates	Participating Approval Date	Insert	New Registration			1/13/2021 2:44 PM
Details	State	Insert	New Registration		Pending	1/13/2021 2:44 PM
Dates	Registration Date	Insert	New Registration		1/13/2021 2:44:31 PM	1/13/2021 2:44 PM
Dates	Signed By Date	Insert	New Registration			1/13/2021 2:44 PM
Dates	Start Date	Insert	New Registration			1/13/2021 2:44 PM
Terminations	Termination Comments	Insert	New Registration			1/13/2021 2:44 PM
Terminations	Termination Date	Insert	New Registration			1/13/2021 2:44 PM
Terminations	Termination Effective Date	Insert	New Registration			1/13/2021 2:44 PM
Terminations	Termination Reason	Insert	New Registration			1/13/2021 2:44 PM