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LAKE REGIONAL PHARMACY-ELDON
SCH260186-05 Lake Regional Health System
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Covered Entity Details
Entity Name
Lake Regional Health System
Subdivision Name
Lake Regional Clinic-Iberia
Type
Sole Community Hospital
340B ID
SCH260186-05
Entity Address
2333 Hwy 17
Iberia, MO 65486
Medicare Provider Number
260186
Outpatient Facility Provider Number
268710
Participating Start Date
1/1/2017
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
LAKE REGIONAL PHARMACY-ELDON
Pharmacy Address
416B S MAPLE ST
ELDON, MO 65026-1812
Pharmacy Comments
Contract Details
Approval Date
4/9/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David W. Halsell, CFO
(573) 348-8388
Contract Pharmacy Representative
Lake Regional Pharmacy-Eldon
Stacie Ling, Director
(573) 302-3185
Signed By Date
4/9/2019
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