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MISSOURI CVS PHARMACY, L.L.C.
CAH261336-00 IRON COUNTY HOSPITAL
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Covered Entity Details
Entity Name
IRON COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261336-00
Entity Address
301 NORTH HWY 21
PILOT KNOB, MO 63663
Medicare Provider Number
261336
Participating Start Date
10/1/2016
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #11206
124 W RUSSELL STREET
IRONTON, MO 63650
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joshua Gilmore, Chief Executive Officer
(573) 546-8003
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/15/2019
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