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CHI HEALTH PHARMACY - LAKESIDE
CAH281342-00 SAINT MARY'S HOSPITAL d/b/a CHI Health St Mary's
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Covered Entity Details
Entity Name
SAINT MARY'S HOSPITAL d/b/a CHI Health St Mary's
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH281342-00
Entity Address
1301 Grundman BLVD
NEBRASKA CITY, NE 68410
Medicare Provider Number
281342
Participating Start Date
9/22/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
CHI HEALTH PHARMACY - LAKESIDE
Pharmacy Address
16909 LAKESIDE HILLS CT STE 107
OMAHA, NE 68130-4661
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/12/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel J DeFreece, Interim President
(402) 873-3321
Contract Pharmacy Representative
CHI Health
Gregory Schardt, Division Director of Pharmacy Operations
(402) 206-3370
Signed By Date
10/14/2019
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