340B Drug Pricing Program Database


DSH140046 SSM HEALTH GOOD SAMARITAN HOSPITAL (ToBeTerminated) - information as of 6/16/2025 2:16:43 AM

Main Details
SSM HEALTH GOOD SAMARITAN HOSPITAL
Disproportionate Share Hospital
Yes
DSH140046
140046


Additional Details
ToBeTerminated
4/6/2023
7/1/2023
6/5/2023
8/15/2024

7/1/2025
Change of covered entity type

Contacts

SSM Health
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219

SSM Health
Holly Herring, Director, 340B Center of Excellence
(580) 512-7188

Addresses

1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864

Same as Street Address


  • Comments
  • Medicaid Billing
  • Shipping Addresses
  • Contract Pharmacies
  • Parent/Child
  • History
Comments
CommentLast Updated On 
No records to display.
Medicaid Billing

Yes
StateMedicaid NumberNPI Number
IL430653587002,4306535874021043270424,1487758801,1609897339,1316282163
Shipping Addresses

Good Samaritan Regional Health CTR
1 Good Samaritan Way
Mt. Vernon, IL 62864

Good Samaritan Plaza Pharmacy
2 Good Samaritan Way, suite 120
Mt. Vernon, IL 62864

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

Centralia Infusion Pharmacy
1052 Martin Luther King Jr Drive
100
Centralia, IL 62801
Contract Pharmacies
Contract DetailPharmacy NameAddressAddress Cont.CityStateZip CodeApproval DateBegin DateCarve-In Effective DateTermination DateLast Updated On
Contract DetailACCREDO HEALTH GROUP INC1620 CENTURY CENTER PKWY # 109
MEMPHISTN38134-884906/05/202307/01/2023 07/01/202505/05/2025
Contract DetailACCREDO HEALTH GROUP INC3000 ERICSSON DRIVE, SUITE 100
WARRENDALEPA15086-750206/05/202307/01/2023 07/01/202505/05/2025
Contract DetailACCREDO HEALTH GROUP INC2040 W RIO SALADO PKWY STE 101B
TEMPEAZ85281-201006/05/202307/01/2023 07/01/202505/05/2025
Contract DetailACCREDO HEALTH GROUP, INC.2 BOULDEN CIR STE 1
NEW CASTLEDE19720-349206/05/202307/01/2023 07/01/202505/05/2025
Contract DetailACCREDO HEALTH GROUP, INC.2825 W PERIMETER RD STE 112
INDIANAPOLISIN4624106/05/202307/01/2023 10/10/202410/17/2024
Contract DetailACCREDO HEALTH GROUP, INC.6272 LEE VISTA BLVD STE 100
ORLANDOFL3282206/05/202307/01/2023 07/01/202505/05/2025
Contract DetailACCREDO HEALTH GROUP, INC.4750 E 450 S SUITE A
WHITESTOWNIN4607506/05/202307/01/2023 07/01/202505/05/2025
Contract DetailBANDY'S APOTHECARY SHOPS INCBANDY'S PHARMACY II 207 E. HURON
PO BOX 526 		IRVINGTONIL6284806/05/202307/01/2023 07/01/202505/05/2025
Contract DetailBANDY'S APOTHECARY SHOPS INC.BANDY'S PHARMACY II 310 S. MAIN STREET
PO BOX 308 		WAYNE CITYIL6289506/05/202307/01/2023 07/01/202505/05/2025
Contract DetailBANDY'S LTC LLCDBA BANDY'S LONG TERM CARE PHARMACY 1415 W WHITTAKER ST
SALEMIL62881-201506/05/202307/01/2023 07/01/202505/05/2025
Contract DetailBANDY'S PHARMACY IIBANDY'S APOTHECARY SHOPS INC. 817 E MCCORD ST
CENTRALIAIL62801-304406/05/202307/01/2023 07/01/202505/05/2025
Contract DetailBANDY'S PHARMACY INC1413 W WHITTAKER ST PO BOX 546
SALEMIL62881-201506/05/202307/01/2023 07/01/202505/05/2025
Contract DetailBIOLOGICSBIOLOGICS BY MCKESSON 13000 WESTON PKWY, STE 105
CARYNC27513-225006/05/202307/01/2023 07/01/202505/05/2025
Contract DetailBIOPLUS SPECIALTY PHARMACY LA, LLC2731 MANHATTAN BLVD STE B17
HARVEYLA7005806/05/202307/01/2023 10/10/202410/17/2024
Contract DetailBIOPLUS SPECIALTY PHARMACY SERVICES, LLC13925 YALE AVE STE 145
IRVINECA92620-267006/05/202307/01/2023 10/10/202410/17/2024
Contract DetailBIOPLUS SPECIALTY PHARMACY SERVICES, LLC376 NORTHLAKE BLVD
ALTAMONTE SPRINGSFL32701-526106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailBIOPLUS SPECIALTY PHARMACY SERVICES, LLC4900 PROSPECTUS DR STE 300
DURHAMNC2771306/05/202307/01/2023 07/01/202505/05/2025
Contract DetailBIOPLUS SPECIALTY PHARMACY SERVICES, LLCBIOPLUS SPECIALTY PHARMACY SERVICES, LLC 4740 VICTORY LN STE C
INDIANAPOLISIN4620310/17/202401/01/2025 07/01/202505/05/2025
Contract DetailBIOPLUS SPECIALTY PHARMACY SERVICES, LLCBIOPLUS SPECIALTY PHARMACY SERVICES, LLC 145 S 79TH ST STE 70
CHANDLERAZ8522610/17/202401/01/2025 07/01/202505/05/2025
Contract DetailBIOPLUS SPECIALTY PHARMACY, INC3200 LAKE EMMA RD UNIT 1000
LAKE MARYFL3274606/05/202307/01/2023 10/10/202410/17/2024
Contract DetailBIOSCRIP INFUSION SERVICES, LLC PHARMACY6 VREELAND RD STE 103
FLORHAM PARKNJ0793206/05/202307/01/2023 07/01/202505/05/2025
Contract DetailBOND DRUG COMPANY OF ILLINOIS, L.L.C.DBA: WALGREENS # 02876 3001 BROADWAY ST
MOUNT VERNONIL6286406/05/202307/01/2023 07/01/202505/05/2025
Contract DetailBYRD-WATSON TIMES SQUARE DRUG3401 BROADWAY ST
MOUNT VERNONIL62864-220106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailCAREMARK FLORIDA SPECIALTY PHARMACY LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7930 WOODLAND CENTER BLVD STE 500
TAMPAFL3361406/05/202307/01/2023 07/01/202505/05/2025
Contract DetailCAREMARK ILLINOIS SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 800 BIERMANN CT STE B
MOUNT PROSPECTIL6005606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailCAREMARK KANSAS SPECIALTY PHARMACYCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 11162 RENNER BLVD
LENEXAKS6621906/05/202307/01/2023 07/01/202505/05/2025
Contract DetailCAREMARK MASSACHUSETTS SPECIALTY PHARMACDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 25 BIRCH STREET, BLDG B, SUITE 100
MILFORDMA0175706/05/202307/01/2023 07/01/202505/05/2025
Contract DetailCAREMARK MICHIGAN SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1307 ALLEN DR STE H
TROYMI4808306/05/202307/01/2023 07/01/202505/05/2025
Contract DetailCAREMARK NEW JERSEY SPECIALTY PHCY, LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 180 PASSAIC AVE UNIT B-5
FAIRFIELDNJ0700406/05/202307/01/2023 07/01/202505/05/2025
Contract DetailCAREMARK NORTH CAROLINA SPECIALTY PHARMADBA CVS/SPECIALTY OR CARELONRX SPECIALTY 10700 WORLD TRADE BLVD STE 110
RALEIGHNC2761706/05/202307/01/2023 07/01/202505/05/2025
Contract DetailCAREMARK TENNESSEE SPECIALTY PHARMACY, LDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 8370 WOLF LAKE DR
STE 107 		BARTLETTTN3813306/05/202307/01/2023 07/01/202505/05/2025
Contract DetailCAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1127 BRYN MAWR AVE
SUITE A 		REDLANDSCA9237406/05/202307/01/2023 07/01/202505/05/2025
Contract DetailCENTERWELL PHARMACY, INC.9843 WINDISCH RD
WEST CHESTEROH4506906/05/202307/01/2023 03/15/202403/15/2024
Contract DetailCVS CAREMARKDBA CVS/CAREMARK OR CF# 11506 1 GREAT VALLEY BOULEVARD
WILKES BARREPA1870606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailCVS CAREMARK ADVANCED TECHNOLOGY PHARMACDBA CVS/CAREMARK 48067 1780 WALL ST
MT PROSPECTIL6005606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailDIPLOMAT SPECIALTY PHARMACY4100 S SAGINAW ST STE D
FLINTMI48507-268306/05/202307/01/2023 07/03/202407/12/2024
Contract DetailDOGWOOD PHARMACY LLCD/B/A MEDSCRIPTS MEDICAL PHARMACY 1325 MILLER RD
STE K 		GREENVILLESC29607-654106/05/202307/01/2023 10/10/202410/17/2024
Contract DetailGENOA HEALTHCARE LLC175 GWINNETT DRIVE, SUITE 111
LAWRENCEVILLEGA3004604/15/202407/01/2024 07/01/202505/05/2025
Contract DetailGENOA HEALTHCARE LLC102 COMPASS POINT DRIVE, STE A
SAINT CHARLESMO6330107/12/202410/01/2024 07/01/202505/05/2025
Contract DetailGENOA HEALTHCARE LLC19515 BRUNE PARKWAY
WARRENTONMO6338307/12/202410/01/2024 07/01/202505/05/2025
Contract DetailGENOA HEALTHCARE LLC1032 CROSSWINDS COURT
WENTZVILLEMO6338507/12/202410/01/2024 07/01/202505/05/2025
Contract DetailGOOD HEALTH INCDBA PREMIER PHARMACY SERVICES 1943 SCHUETZ RD
SAINT LOUISMO63146-355006/05/202307/01/2023 07/01/202505/05/2025
Contract DetailHIGHLAND PARK CVS, L.L.C.DBA CVS/PHARMACY #18091 1129 W BROADWAY
CENTRALIAIL6280106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailHIGHLAND PARK CVS, L.L.C.DBA: CVS/PHARMACY # 06373 304 W. MAIN ST.
WEST FRANKFORTIL6289606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailHIGHLAND PARK CVS, L.L.C.DBA: CVS/PHARMACY # 06385 1301 N. STATE ST.
FLORAIL6283906/05/202307/01/2023 07/01/202505/05/2025
Contract DetailHIGHLAND PARK CVS, L.L.C.DBA: CVS/PHARMACY # 06370 2700 BROADWAY
MOUNT VERNONIL6286406/05/202307/01/2023 07/01/202505/05/2025
Contract DetailHIGHLAND PARK CVS, L.L.C.DBA: CVS/PHARMACY # 06886 1101 W. MAIN ST.
CARMIIL6282106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailHIGHLAND PARK CVS, L.L.C.DBA: CVS/PHARMACY # 06921 225 N. POPLAR ST.
CENTRALIAIL6280106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailHIGHLAND PARK CVS, L.L.C.DBA: CVS/PHARMACY # 06885 700 W. MAIN ST.
FAIRFIELDIL6283706/05/202307/01/2023 07/01/202505/05/2025
Contract DetailHIGHLAND PARK CVS, L.L.C.DBA: CVS/PHARMACY # 06372 705 WEST MAINST.
BENTONIL6281206/05/202307/01/2023 07/01/202505/05/2025
Contract DetailHIGHLAND PARK CVS, L.L.C.DBA: CVS/PHARMACY # 06389 1022 W. MAIN ST.
SALEMIL6288106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailKENTUCKY CENTRAL FILL FACILITY, L-0105594 SHEPHERDSVILLE ROAD
LOUISVILLEKY40228-101206/05/202307/01/2023 07/01/202505/05/2025
Contract DetailKroger PharmacyJeffersonville Central Fill Facility 301 Logistics Ave
Suite 200 		JeffersonvilleIN4713006/05/202307/01/2023 07/01/202505/05/2025
Contract DetailLUMICERA HEALTH SERVICES, LLC310 INTEGRITY DRIVE
MADISONWI53717-149906/05/202307/01/2023 12/31/202301/16/2024
Contract DetailOPTION CARE ENTERPRISES, INC.OPTION CARE 535 AXMINISTER DRIVE
FENTONMO63026-290306/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTION CARE ENTERPRISES, INC.D/B/A OPTION CARE 11403 BLUEGRASS PARKWAY
SUITE 400 		LOUISVILLEKY40299-239806/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTION CARE ENTERPRISES, INC.OPTION CARE 870 N. ARLINGTON HEIGHTS RD
SUITE 101 		ITASCAIL6014306/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM FRONTIER THERAPIES II, LLC6425 SANTA MARGARITA ST UNIT 110
LAS VEGASNV89118-191307/12/202410/01/2024 07/01/202505/05/2025
Contract DetailOPTUM FRONTIER THERAPIES, LLC325 W ATHERTON RD SUITE 1
FLINTMI48507-260107/12/202410/01/2024 07/01/202505/05/2025
Contract DetailOPTUM INFUSION SERVICES 103, LLC9204 BERGER RD. STE. A
COLUMBIAMD21046-172906/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM INFUSION SERVICES 301, LP7512 NORTH BROADWAY EXT STE 308
OKLAHOMA CITYOK73116-905506/05/202307/01/2023 10/10/202410/17/2024
Contract DetailOPTUM INFUSION SERVICES 302, LLC8720 S 114TH ST STE 106
LA VISTANE68128-558506/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM INFUSION SERVICES 305, LLC4000 CHEMICAL RD STE 100
PLYMOUTH MEETINGPA1946206/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM INFUSION SERVICES 305, LLC15529 COLLEGE BLVD.
LENEXAKS66219-135106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM INFUSION SERVICES 500, INC.2685 PATTON RD
ROSEVILLEMN5511306/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM INFUSION SERVICES 501, INC.1867 LACKLAND HILL PKWY
SAINT LOUISMO6314606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM INFUSION SERVICES 550, LLC10607 & 10611 AURORA AVE.
URBANDALEIA5032206/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM INFUSION SERVICES 550, LLC7167 E. KEMPER RD.
CINCINNATIOH4524906/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM INFUSION SERVICES 550, LLC1819 ASTON AVE STE 104
CARLSBADCA9200806/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM INFUSION SERVICES 553, LLC6531 MERIDIEN DR SUITE 113
RALEIGHNC2761606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 700, LLC5700 DOT COM CT, STE 1000
OVIEDOFL3276506/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 701, LLC8131 W BOSTIAN RD STE A350
WOODINVILLEWA98072-502906/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 701, LLC4100 S SAGINAW ST STE D
FLINTMI4850706/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 701, LLC1830 S HORNE
MESAAZ8520401/16/202404/01/2024 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 701, LLC4015 SHOPTON RD STE 600
CHARLOTTENC28217-302504/15/202407/01/2024 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 702, LLC1050 PATROL RD
JEFFERSONVILLEIN4713006/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 705, LLC1893 GENERAL GEORGE PATTON DR STE 106
FRANKLINTN37067-265506/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 705, LLC3539 BLUECUTT RD
COLUMBUSMS3970506/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 705, LLC11142 RENNER BLVD
LENEXAKS6621906/05/202307/01/2023 10/10/202410/17/2024
Contract DetailOPTUM PHARMACY 705, LLC1100 LEE BRANCH LN
BIRMINGHAMAL35242-729806/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 706, INC.30-30 47TH AVENUE SUITE 410
LONG ISLAND CITYNY1110106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 707, INC4900 RIVERGRADE RD STE E110
IRWINDALECA91706-140110/17/202401/01/2025 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 801, INC.24416 N 19TH AVE STE. 100
PHOENIXAZ8508506/05/202307/01/2023 07/01/202505/05/2025
Contract DetailOPTUM PHARMACY 805, INC1101 N CENTRAL AVE, STE 102
PHOENIXAZ85004-182906/05/202307/01/2023 10/10/202410/17/2024
Contract DetailOPTUM PHARMACY 806, INC.2288 AUBURN BLVD STE. 102
SACRAMENTOCA95821-161806/05/202307/01/2023 10/10/202410/17/2024
Contract DetailOPTUMRXOPTUMRX INC 6800 W 115TH ST STE 600
OVERLAND PARKKS66211-983806/05/202307/01/2023 07/01/202505/05/2025
Contract DetailPREMIER PHARMACY SERVICES410 CLOVERLEAF DR
BALDWIN PARKCA9170606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailPROCARE PHARMACY DIRECT, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 105 MALL BOULEVARD
MONROEVILLEPA1514606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailRAINA RX LLCDBA ROUTE 300 PHARMACY 1208 ROUTE 300
SUITE 103 		NEWBURGHNY1255006/05/202307/01/2023 10/10/202410/17/2024
Contract DetailRIVER MEDICAL PHARMACY LLC4752 RESEARCH DR
SAN ANTONIOTX78240-500206/05/202307/01/2023 10/10/202410/17/2024
Contract DetailSANTA BARBARA SPECIALTY PHARMACY LLC4690 CARPINTERIA AVE STE B
CARPINTERIACA9301306/05/202307/01/2023 10/10/202410/17/2024
Contract DetailSENDERRA RX PHARMACYSENDERRA RX PARTNERS, LLC 3712 E PLANO PKWY STE 200
PLANOTX7507406/05/202307/01/2023 07/01/202505/05/2025
Contract DetailSSM HEALTH PHARMACY1211 FISH HATCHERY RD STE 300
MADISONWI5371506/05/202307/01/2023 03/31/202404/15/2024
Contract DetailSSM HEALTH PHARMACY310 INTEGRITY DR
MADISONWI53717-141606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailSSM HEALTH SPECIALTY PHARMACYSSM HEALTH CARE ST. LOUIS - OWNER 3662 PARK AVE STE 155
SAINT LOUISMO6311006/05/202307/01/2023 07/01/202505/05/2025
Contract DetailTHE KROGER CO415 S 42ND ST
MOUNT VERNONIL6286406/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART CENTRAL FILL 10-2670608 SPRING HILL DR # 3 SUITE 300
SPRINGTX7738606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-01961450 EAST MAIN
CARBONDALEIL6290106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-01981870 WEST MAIN STREET
SALEMIL6288106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-02012608 GREEN MOUNT COMMONS DR
BELLEVILLEIL6222106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-02162802 OUTER ROAD DRIVE
MARIONIL6295906/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-02221410 NORTH MARKET STREET
SPARTAIL6228606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-0224110 DAVIDSON AVENUE
MOUNT VERNONIL6286406/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-0237710 SOUTH COMMERCIAL
HARRISBURGIL6294606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-0252215 GRANT WAY
DU QUOINIL6283206/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-0262919 GIACONE DR
BENTONIL6281206/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-03026495 COUNTRY CLUB RD
MURPHYSBOROIL6296606/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-0317201 NORTH MATTES AVE
VANDALIAIL6247106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-043512495 STATE ROUTE 143
HIGHLANDIL6224906/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-04362591 12TH STREET
CARLYLEIL6223106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-0454150 COMMERCE DR.
FAIRFIELDIL6283706/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-05061540 N WORTHY
FLORAIL6283906/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-05961713 S. PARK AVE.
HERRINIL6294806/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-08331344 ILLINOIS HWY #1
CARMIIL6282106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-09361204 AVE OF MID AMERICA
EFFINGHAMIL6240106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-13951212 WEST MCCORD
CENTRALIAIL6280106/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-14181530 WEST HWY 50
O'FALLONIL6226906/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-53152354 COMMERCE PARK DR.
ORLANDOFL3281906/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWAL-MART PHARMACY 10-59979600 PARKSOUTH CT. SUITE 100
ORLANDOFL3283706/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWALGREEN CO.DBA WALGREENS SPECIALTY PHARMACY #21346 3527 CHOUTEAU AVE
SAINT LOUISMO6310306/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWALGREEN CO.DBA WALGREENS SPECIALTY PHARMACY #15311 115 N EUCLID AVE STE A
SAINT LOUISMO6310806/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWALGREEN CO.DBA: WALGREENS # 07236 225 NORTH ELM STREET
CENTRALIAIL62801-324806/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWalgreens Central Fill #213942601 Hughes Road
Suite 103 		LibertyMO6406806/05/202307/01/2023 07/01/202505/05/2025
Contract DetailWALMART PHARMACY 10-51692252 NORTH 8TH STREET
SUITE A 		ROGERSAR7275610/11/202301/01/2024 07/01/202505/05/2025
Contract DetailWalmart Pharmacy 10-76112501 Perry Rd
PlainfieldIN4616810/11/202301/01/2024 07/01/202505/05/2025
Parent/Child
340B IDHierarchyEntity TypeNameSub NameAddressCityState340B Status
DSH140046AChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Medical Plaza Urology [CC-746100]2 Good Samaritan WayMt. VernonILToBeTerminated
DSH140046BChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Pulmonary Care2 Good Samaritan WayMt. VernonILToBeTerminated
DSH140046CChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSSM HEALTH GOOD SAMARITAN HOSPITAL- - SMGS - Oncology4117 VETERANS MEMORIAL DRMOUNT VERNONILToBeTerminated
DSH140046DChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALGOOD SAMARITAN REGIONAL HEALTH CENT - SMGS - Wound Healing Center4106 S WATER TOWER PLMOUNT VERNONILToBeTerminated
DSH140046EChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - General Surgery5 Good Samaritan WayMt. VernonILToBeTerminated
DSH140046FChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Heart and Vascular2 Good Samaritan WayMt. VernonILToBeTerminated
DSH140046GChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Rheumatology2 Good Samaritan WayMt. VernonILTerminated
DSH140046HChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Nephrology2 Good Samaritan WayMt. VernonILToBeTerminated
DSH140046JChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Medical Plaza Vascular Surgery2 Good Samaritan WayMt. VernonILToBeTerminated
DSH140046KChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Weight Management5 Good Samaritan WayMt. VernonILToBeTerminated
DSH140046LChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Medical Plaza Urology [CC-74600]2 Good Samaritan WayMt. VernonILTerminated
DSH140046MChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSSM HEALTH GOOD SAMARITAN HOSPITAL- - SMGS - Oncology Infusion4117 VETERANS MEMORIAL DRMOUNT VERNONILToBeTerminated
DSH140046NChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - GI2 Good Samaritan WayMt. VernonILToBeTerminated
DSH140046PChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Infectious Disease2 Good Samaritan WayMt. VernonILTerminated
DSH140046QChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Endocrinology 5GS5 Good Samaritan WayMt. VernonILTerminated
DSH140046RChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Endocrinology 2GS2 Good Samaritan WayMount VernonILToBeTerminated
DSH140046SChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Physical Medicine and Rehab2 Good Samaritan WayMt. VernonILTerminated
DSH140046TChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALSMGS - - Medical Plaza Podiatry2 Good Samaritan WayMt. VernonILToBeTerminated
DSH140046UChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALBehavioral Health Clinic - MV Behavioral Health2 Good Samaritan WayMt. VernonILToBeTerminated
DSH140046VChildDSHSSM HEALTH GOOD SAMARITAN HOSPITALGood Samaritan Infusion Centralia - Infusion400 North Pleasant AvenueCentraliaILToBeTerminated
History
SectionFieldActionActivityValue BeforeValue AfterTimestamp 
DatesLast Date That 340B Drugs PurchasedUpdateHospital Type Change Request 7/1/2025 12:00:00 AM5/5/2025 12:40 PM
DetailsStateUpdateHospital Type Change RequestActiveTo Be Terminated5/5/2025 12:40 PM
TerminationsTermination DateUpdateHospital Type Change Request 7/1/2025 12:00:00 AM5/5/2025 12:40 PM
TerminationsTermination Effective DateUpdateHospital Type Change Request 7/1/2025 12:00:00 AM5/5/2025 12:40 PM
TerminationsTermination ReasonUpdateHospital Type Change Request Change of covered entity type5/5/2025 12:40 PM
DetailsLast Recertification DateUpdateRecertification9/12/2023 8:04:44 AM8/15/2024 1:38:10 PM8/15/2024 1:38 PM
AddressesShipping AddressInsertChange Request Centralia Infusion Pharmacy 1052 Martin Luther King Jr Drive 100 Centralia, IL 6280110/23/2023 12:12 PM
ContactsPrimary ContactUpdatePC Change RequestSchmitt, Michelle Nicole Director of Business Operations SSM Health 6082846203Herring, Holly Director, 340B Center of Excellence SSM Health 580512718810/2/2023 7:35 AM
AddressesShipping AddressDeleteRecertificationSSM Health Medication Purchasing 2202 W Beltline Hwy Madison, WI 53713 9/12/2023 8:04 AM
AddressesShipping AddressInsertRecertification SSM Health Medication Purchasing 2201 W Badger Rd Madison, WI 537139/12/2023 8:04 AM
DetailsLast Recertification DateUpdateRecertification 9/12/2023 8:04:44 AM9/12/2023 8:04 AM
DetailsStateUpdate ApprovedActive7/1/2023 12:01 AM
ContactsPrimary ContactUpdateChange RequestMcAllister, Anita System Director of 340B Operations SSM Health 3149896778Schmitt, Michelle Nicole Director of Business Operations SSM Health 60828462036/23/2023 1:23 PM
ContactsSigned ByInsertHospital Type Change Request Lamm, Eileen Regional Vice President-Finance SSM Health 31499462196/5/2023 8:18 AM
Details340B IDUpdateHospital Type Change Request DSH1400466/5/2023 8:18 AM
DatesParticipating Approval DateUpdateHospital Type Change Request 6/5/2023 8:18:35 AM6/5/2023 8:18 AM
DetailsStateUpdateHospital Type Change RequestPendingApproved6/5/2023 8:18 AM
DatesSigned By DateUpdateHospital Type Change Request 5/8/2023 10:34:56 AM6/5/2023 8:18 AM
DatesStart DateUpdateHospital Type Change Request 7/1/2023 12:00:00 AM6/5/2023 8:18 AM
AddressesMain AddressInsertHospital Type Change Request  1 GOOD SAMARITAN WAY MT. VERNON, IL 628644/6/2023 8:32 PM
AddressesShipping AddressInsertHospital Type Change Request Good Samaritan Regional Health CTR 1 Good Samaritan Way Mt. Vernon, IL 628644/6/2023 8:32 PM
AddressesShipping AddressInsertHospital Type Change Request Good Samaritan Plaza Pharmacy 2 Good Samaritan Way, suite 120 Mt. Vernon, IL 628644/6/2023 8:32 PM
AddressesShipping AddressInsertHospital Type Change Request SSM Health Medication Purchasing 2202 W Beltline Hwy Madison, WI 537134/6/2023 8:32 PM
Medicaid BillingMedicaid: Is PrimaryInsertHospital Type Change Request False4/6/2023 8:32 PM
Medicaid BillingMedicaid: NumberInsertHospital Type Change Request 4306535870024/6/2023 8:32 PM
Medicaid BillingMedicaid: StateInsertHospital Type Change Request IL4/6/2023 8:32 PM
Medicaid BillingMedicaid: Is PrimaryInsertHospital Type Change Request False4/6/2023 8:32 PM
Medicaid BillingMedicaid: NumberInsertHospital Type Change Request 4306535874024/6/2023 8:32 PM
Medicaid BillingMedicaid: StateInsertHospital Type Change Request IL4/6/2023 8:32 PM
Medicaid BillingNPI: NumberInsertHospital Type Change Request 10432704244/6/2023 8:32 PM
Medicaid BillingNPI: StateInsertHospital Type Change Request IL4/6/2023 8:32 PM
Medicaid BillingNPI: NumberInsertHospital Type Change Request 14877588014/6/2023 8:32 PM
Medicaid BillingNPI: StateInsertHospital Type Change Request IL4/6/2023 8:32 PM
Medicaid BillingNPI: NumberInsertHospital Type Change Request 16098973394/6/2023 8:32 PM
Medicaid BillingNPI: StateInsertHospital Type Change Request IL4/6/2023 8:32 PM
Medicaid BillingNPI: NumberInsertHospital Type Change Request 13162821634/6/2023 8:32 PM
Medicaid BillingNPI: StateInsertHospital Type Change Request IL4/6/2023 8:32 PM
ContactsAuthorizing OfficialInsertHospital Type Change Request Lamm, Eileen Regional Vice President-Finance SSM Health 31499462194/6/2023 8:32 PM
ContactsPrimary ContactInsertHospital Type Change Request McAllister, Anita System Director of 340B Operations SSM Health 31498967784/6/2023 8:32 PM
DetailsAssistance Received From DateInsertHospital Type Change Request  4/6/2023 8:32 PM
DetailsAssistance Received To DateInsertHospital Type Change Request  4/6/2023 8:32 PM
DetailsLast Recertification DateInsertHospital Type Change Request  4/6/2023 8:32 PM
DetailsGrant NumberInsertHospital Type Change Request  4/6/2023 8:32 PM
Details340B IDInsertHospital Type Change Request  4/6/2023 8:32 PM
DetailsIs Authorizing Official EHB DataInsertHospital Type Change Request  4/6/2023 8:32 PM
DatesLast Date That 340B Drugs PurchasedInsertHospital Type Change Request  4/6/2023 8:32 PM
DetailsMedicare Provider NumberInsertHospital Type Change Request 1400464/6/2023 8:32 PM
DetailsEntity NameInsertHospital Type Change Request SSM HEALTH GOOD SAMARITAN HOSPITAL4/6/2023 8:32 PM
DetailsNOFO NumberInsertHospital Type Change Request  4/6/2023 8:32 PM
DetailsProgram CodeInsertHospital Type Change Request DSH4/6/2023 8:32 PM
DetailsEntity SubnameInsertHospital Type Change Request  4/6/2023 8:32 PM
DatesParticipating Approval DateInsertHospital Type Change Request  4/6/2023 8:32 PM
DetailsStateInsertHospital Type Change Request Pending4/6/2023 8:32 PM
DatesRegistration DateInsertHospital Type Change Request 4/6/2023 8:32:13 PM4/6/2023 8:32 PM
DatesSigned By DateInsertHospital Type Change Request  4/6/2023 8:32 PM
DatesStart DateInsertHospital Type Change Request  4/6/2023 8:32 PM
TerminationsTermination CommentsInsertHospital Type Change Request  4/6/2023 8:32 PM
TerminationsTermination DateInsertHospital Type Change Request  4/6/2023 8:32 PM
TerminationsTermination Effective DateInsertHospital Type Change Request  4/6/2023 8:32 PM
TerminationsTermination ReasonInsertHospital Type Change Request  4/6/2023 8:32 PM