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MISSOURI CVS PHARMACY, L.L.C.
CAH261332-00 Carroll County Memorial Hospital
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Covered Entity Details
Entity Name
Carroll County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261332-00
Entity Address
1502 N Jefferson
Carrollton, MO 64633
Medicare Provider Number
261332
Participating Start Date
4/1/2013
Last Recertification Date
8/13/2024
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
7/8/2020
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
Tim Braun, Chief Operating Officer
(660) 542-1695 Ext: 3067
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/8/2020
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