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MISSOURI CVS PHARMACY, L.L.C.
SCH260142-01 JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
Grand River Medical Clinic
Type
Sole Community Hospital
340B ID
SCH260142-01
Entity Address
815 E. Broadway
Brunswick, MO 65236
Medicare Provider Number
260142
Outpatient Facility Provider Number
Participating Start Date
10/1/2019
Last Recertification Date
Entity Termination Date
1/1/2020
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #11316
941 CHEROKEE DR STE 1
MARSHALL, MO 65340
Pharmacy Comments
Contract Details
Approval Date
7/9/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Angy P. Littrell, President & CEO
(660) 831-3251
Contract Pharmacy Representative
CVS Health
Gina Lohr, 340B Regional Director
(401) 537-8808
Signed By Date
7/9/2018
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