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WALGREEN CO.
DSH260160 SOUTHEASTHEALTH CENTER OF STODDARD CTY; dba MERCY HOSPITAL STODDARD
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Covered Entity Details
Entity Name
SOUTHEASTHEALTH CENTER OF STODDARD CTY; dba 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
WALGREENS #15801
310 W MAIN STREET
MALDEN, MO 63863
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
2/23/2023
Pharmacy closed
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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