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MISSOURI CVS PHARMACY, L.L.C.
SCH260097-00 WESTERN MISSOURI MEDICAL CENTER
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Covered Entity Details
Entity Name
WESTERN MISSOURI MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH260097-00
Entity Address
403 BURKARTH ROAD
WARRENSBURG, MO 64093
Medicare Provider Number
260097
Participating Start Date
10/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #11312
1030 MAIN STREET
LEXINGTON, MO 64067
Pharmacy Comments
Contract Details
Approval Date
10/8/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dean Ohmart, Chief Financial Officer
(660) 262-7307
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/8/2019
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