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MISSOURI CVS PHARMACY, L.L.C.
DSH260113 MISSOURI DELTA MEDICAL CENTER
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Covered Entity Details
Entity Name
MISSOURI DELTA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260113
Entity Address
1008 NORTH MAIN
SIKESTON, MO 63801
Medicare Provider Number
260113
Participating Start Date
7/1/2006
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
CVS PHARMACY # 16385
202 SIEMERS DR
CAPE GIRARDEAU, MO 63701
Pharmacy Comments
Contract Details
Approval Date
10/9/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JASON SCHRUMPF, CEO
(573) 472-7600
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/9/2018
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