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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
2505 MISSION DR
STE 110
JEFFERSON CITY, MO 65109
Pharmacy Comments
Contract Details
Approval Date
10/3/2019
Contract Begin Date
1/1/2020
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
Robert Ritchey, Regional Pharmacy Director
(573) 681-3168
Signed By Date
10/3/2019
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