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MISSOURI CVS PHARMACY, L.L.C.
DSH260195 CITIZENS MEMORIAL HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
CITIZENS MEMORIAL HOSPITAL DISTRICT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260195
Entity Address
1500 NORTH OAKLAND
BOLIVAR, MO 65613
Medicare Provider Number
260195
Participating Start Date
4/1/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 10152
1501 E. OHIO ST.
CLINTON, MO 64735
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gary Dene Fulbright, Chief Financial Officer
(417) 328-6402
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/14/2019
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