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MEDICAP PHARMACY
DSH260113 MISSOURI DELTA MEDICAL CENTER
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Covered Entity Details
Entity Name
MISSOURI DELTA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260113
Entity Address
1008 NORTH MAIN
SIKESTON, MO 63801
Medicare Provider Number
260113
Participating Start Date
7/1/2006
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
MEDICAP PHARMACY
Pharmacy Address
211 W YOAKUM AVE
TEE'S, INC.
CHAFFEE, MO 63740-1138
Pharmacy Comments
Contract Details
Approval Date
10/16/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/21/2020
Ownership change
Contacts
Covered Entity Signing Official
JASON SCHRUMPF, CEO
(573) 472-7600
Contract Pharmacy Representative
Tee's, Inc.
Gerald Kevin Teegarden, President
(573) 887-3622
Signed By Date
10/16/2019
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