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SWEET SPRINGS INC
DSH260142B JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
Grand River Medical Clinic
Type
Disproportionate Share Hospital
340B ID
DSH260142B
Entity Address
815 E. Broadway
Brunswick, MO 65236
Medicare Provider Number
260142
Outpatient Facility Provider Number
Participating Start Date
1/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
SWEET SPRINGS INC
Pharmacy Address
MARCELINE FAMILY PHARMACY
1509 N MISSOURI AVE
MARCELINE, MO 64658
Pharmacy Comments
Contract Details
Approval Date
10/5/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/18/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Angy P. Littrell, President & CEO
(660) 831-3251
Contract Pharmacy Representative
The Market
Tony Clark, Director of Operations
(660) 247-1580
Signed By Date
10/5/2020
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