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HOMETOWN PHARMACY MARSHALL
DSH260142A JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
Akeman-McBurney Medical Clinic
Type
Disproportionate Share Hospital
340B ID
DSH260142A
Entity Address
420 W. Front St.
Slater, MO 65349-1328
Medicare Provider Number
260142
Outpatient Facility Provider Number
Participating Start Date
1/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
HOMETOWN PHARMACY MARSHALL
Pharmacy Address
452 W ARROW ST
MARSHALL, MO 65340-1905
Pharmacy Comments
Contract Details
Approval Date
7/1/2019
Contract Begin Date
10/1/2019
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
Palmco, Inc.
J. Michael Palmer, CEO
(660) 707-3972
Signed By Date
7/1/2019
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