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MISSOURI CVS PHARMACY, L.L.C.
DSH260142 JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260142
Entity Address
2305 SOUTH HIGHWAY 65
MARSHALL, MO 65340
Medicare Provider Number
260142
Participating Start Date
1/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #11311
1003 N US HIGHWAY 65
CARROLLTON, MO 64633
Pharmacy Comments
Contract Details
Approval Date
7/7/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/18/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Angy P. Littrell, President & CEO
(660) 831-3251
Contract Pharmacy Representative
CVS Health
Gina Lohr, 340B Regional Director
(401) 537-8808
Signed By Date
7/7/2020
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