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MISSOURI CVS PHARMACY, L.L.C.
DSH260091AA SSM HEALTH ST MARY'S HOSPITAL-STL
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Covered Entity Details
Entity Name
SSM HEALTH ST MARY'S HOSPITAL-STL
Subdivision Name
SSM Cardinal Glennon Children's Hospital Pediatric GU
Type
Disproportionate Share Hospital
340B ID
DSH260091AA
Entity Address
1465 South Grand Blvd.
St. Louis, MO 63104
Medicare Provider Number
260091
Outpatient Facility Provider Number
Participating Start Date
4/1/2015
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #18064
60 HAMPTON VILLAGE PLZ
SAINT LOUIS, MO 63109-2127
Pharmacy Comments
Contract Details
Approval Date
9/25/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219
Contract Pharmacy Representative
cvs
Christian Reid, 340B Program Director
(401) 770-2118
Signed By Date
9/25/2020
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