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BANDY'S PHARMACY II
RRC140046-00 SSM HEALTH GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140046-00
Entity Address
1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864
Medicare Provider Number
140046
Participating Start Date
7/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
BANDY'S PHARMACY II
Pharmacy Address
BANDY'S APOTHECARY SHOPS INC
500 S. 10TH STREET
MOUNT VERNON, IL 62864
Pharmacy Comments
Contract Details
Approval Date
7/14/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Jeremy Shawn Bradford, President
(618) 899-1002
Contract Pharmacy Representative
Bandy's
Eric Bandy, CFO
(618) 548-4000
Signed By Date
7/14/2019
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