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KANSAS CVS PHARMACY, L.L.C.
DSH260006 HEARTLAND REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
HEARTLAND REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260006
Entity Address
5325 FARAON
ST. JOSEPH, MO 64506-3398
Medicare Provider Number
260006
Participating Start Date
1/1/2024
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
KANSAS CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05889
400 SOUTH 10TH ST.
ATCHISON, KS 66002
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Dwain Stilson, Chief Financial Officer
(816) 271-7070
Contract Pharmacy Representative
CVS
Christian Reid, 340B Program Director, CVS Pharmacy
(401) 770-2118
Signed By Date
4/13/2020
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