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COUNTY MARKET PHARMACY 392
CAH261333-00 Pike County Memorial Hospital
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Covered Entity Details
Entity Name
Pike County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261333-00
Entity Address
2305 Georgia Street
Louisiana, MO 63353
Medicare Provider Number
261333
Participating Start Date
7/1/2012
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
COUNTY MARKET PHARMACY 392
Pharmacy Address
NIEMANN FOODS INC
1555 US 54 WEST
VANDALIA, MO 63382
Pharmacy Comments
Contract Details
Approval Date
7/10/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Justin Selle, Chief Executive Officer
(573) 754-5531 Ext: 103
Contract Pharmacy Representative
Niemann Foods Inc
Joe Salois, Pharmacist
(573) 594-2136
Signed By Date
7/10/2018
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