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SAM'S HEALTH MART PHARMACY #3
DSH260141 University of Missouri Health Care
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Covered Entity Details
Entity Name
University of Missouri Health Care
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260141
Entity Address
One Hospital Drive
Columbia, MO 65212
Medicare Provider Number
260141
Participating Start Date
12/1/1992
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SAM'S HEALTH MART PHARMACY #3
Pharmacy Address
SAM'S PRESCRIPTION SHOP INC
300 N. CHURCH ST.
PO BOX 509
FAYETTE, MO 65248-0509
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jonathan Curtright, CEO
(573) 884-8738
Contract Pharmacy Representative
Sam's Health Mart Pharmacies
Christian Tadrus, Owner/Pharmacist
(660) 263-3514
Signed By Date
7/12/2019
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