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MISSOURI CVS PHARMACY, L.L.C.
CAH261322-00 Excelsior Spring City Hospital DBA Excelsior Springs Hospital
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Covered Entity Details
Entity Name
Excelsior Spring City Hospital DBA Excelsior Springs Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261322-00
Entity Address
1700 Rainbow Blvd
Excelsior Springs, MO 64024
Medicare Provider Number
261322
Participating Start Date
10/1/2011
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #11309
1018 N JESSE JAMES RD
EXCELSIOR SPRINGS, MO 64024
Pharmacy Comments
Contract Details
Approval Date
11/19/2018
Contract Begin Date
11/19/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/15/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Nanette Houck, Interim CEO
(816) 630-6081 Ext: 2742
Contract Pharmacy Representative
Excelsior Springs Houck
Nanette Houck, Interim CEO
(816) 630-6081 Ext: 2742
Signed By Date
11/19/2018
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