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WALGREEN CO.
SCH260064-00 SSM HEALTH-ST.MARY'S AUDRAIN
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Covered Entity Details
Entity Name
SSM HEALTH-ST.MARY'S AUDRAIN
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH260064-00
Entity Address
620 E MONROE
MEXICO, MO 65265
Medicare Provider Number
260064
Participating Start Date
7/1/2018
Last Recertification Date
8/28/2019
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 10587
101 N WESTERN ST
MEXICO, MO 65265
Pharmacy Comments
Contract Details
Approval Date
4/23/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Donna Jacobs, President, SSM Audrain Health Center
(573) 582-8103
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/23/2018
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