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SSM HEALTH PHARMACY
SCH260064-00 SSM HEALTH-ST.MARY'S AUDRAIN
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Covered Entity Details
Entity Name
SSM HEALTH-ST.MARY'S AUDRAIN
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH260064-00
Entity Address
620 E MONROE
MEXICO, MO 65265
Medicare Provider Number
260064
Participating Start Date
7/1/2018
Last Recertification Date
8/28/2019
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
SSM HEALTH PHARMACY
Pharmacy Address
1211 FISH HATCHERY RD STE 300
MADISON, WI 53715
Pharmacy Comments
Contract Details
Approval Date
1/11/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Donna Jacobs, President, SSM Audrain Health Center
(573) 582-8103
Contract Pharmacy Representative
SSM Health
Eric Huckins, Pharmacy Manager
(608) 824-2682
Signed By Date
1/11/2019
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