Contract Pharmacy Details

MISSOURI CVS PHARMACY, L.L.C.
SCH260006-00 HEARTLAND REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

HEARTLAND REGIONAL MEDICAL CENTER

Subdivision Name

Type

Sole Community Hospital

340B ID

SCH260006-00

Entity Address

5325 FARAON
ST. JOSEPH, MO 64506-3398

Medicare Provider Number

260006

Participating Start Date

10/1/2020

Last Recertification Date

8/30/2023

Entity Termination Date

1/1/2024

Pharmacy Details

Pharmacy Name

MISSOURI CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 08596
601 S. JEFFERSON ST.
KEARNEY, MO 64060

Pharmacy Comments

Contract Details

Approval Date

10/11/2018

Contract Begin Date

1/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2020
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Dwain Stilson, Chief Financial Officer
(816) 271-7070

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

10/11/2018

340B Drug Pricing Program Database