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MISSOURI CVS PHARMACY, L.L.C.
DSH260195 CITIZENS MEMORIAL HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
CITIZENS MEMORIAL HOSPITAL DISTRICT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260195
Entity Address
1500 NORTH OAKLAND
BOLIVAR, MO 65613
Medicare Provider Number
260195
Participating Start Date
4/1/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 3897
3030 SOUTH CAMPBELL AVE
SPRINGFIELD, MO 65807
Pharmacy Comments
Contract Details
Approval Date
7/2/2020
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/9/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Renee Marie Meyer, Chief Financial Officer
(417) 328-6258
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/2/2020
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