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HOMETOWN PHARMACY MARSHALL
DSH260142B JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
Grand River Medical Clinic
Type
Disproportionate Share Hospital
340B ID
DSH260142B
Entity Address
815 E. Broadway
Brunswick, MO 65236
Medicare Provider Number
260142
Outpatient Facility Provider Number
Participating Start Date
1/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
HOMETOWN PHARMACY MARSHALL
Pharmacy Address
452 W ARROW ST
MARSHALL, MO 65340-1905
Pharmacy Comments
Contract Details
Approval Date
2/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/28/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Angy P. Littrell, President & CEO
(660) 831-3251
Contract Pharmacy Representative
Palmco, Inc.
J. Michael Palmer, CEO
(660) 707-3972
Signed By Date
2/14/2020
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