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NIV ACQUISITION LLC
CAH261308-00 Washington County Memorial Hospital
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Covered Entity Details
Entity Name
Washington County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261308-00
Entity Address
300 Health Way
Potosi, MO 63664
Medicare Provider Number
261308
Participating Start Date
4/1/2012
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
NIV ACQUISITION LLC
Pharmacy Address
DBA OMNICARE OF QUINCY
1114 BROADWAY
QUINCY, IL 62301
Pharmacy Comments
Contract Details
Approval Date
10/2/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/24/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Amber Coleman, Director of Support Services
(573) 438-5451 Ext: 257
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/2/2020
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