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MISSOURI CVS PHARMACY, L.L.C.
DSH260142B JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
Grand River Medical Clinic
Type
Disproportionate Share Hospital
340B ID
DSH260142B
Entity Address
815 E. Broadway
Brunswick, MO 65236
Medicare Provider Number
260142
Outpatient Facility Provider Number
Participating Start Date
1/1/2020
Last Recertification Date
9/3/2024
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
11/7/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/19/2019
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
10/16/2018
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