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WALGREEN CO.
DSH260160 Mercy Hospital Stoddard
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Covered Entity Details
Entity Name
Mercy Hospital Stoddard
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260160
Entity Address
1200 NORTH ONE MILE ROAD
DEXTER, MO 63841
Medicare Provider Number
260160
Participating Start Date
7/1/2019
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 10153
110 N WESTWOOD BLVD
POPLAR BLUFF, MO 63901
Pharmacy Comments
Contract Details
Approval Date
4/6/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/5/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sue Ann Williams, CEO
(573) 614-1900
Contract Pharmacy Representative
Southeast Hospital of Stoddard County
Sherrie Lane, Director of Pharmacy
(573) 331-6076
Signed By Date
4/6/2020
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