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HIGHLAND PARK CVS, L.L.C.
RRC140046-00 SSM HEALTH GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140046-00
Entity Address
1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864
Medicare Provider Number
140046
Participating Start Date
7/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #18091
1129 W BROADWAY
CENTRALIA, IL 62801
Pharmacy Comments
Contract Details
Approval Date
10/7/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jeremy Shawn Bradford, President
(618) 899-1002
Contract Pharmacy Representative
cvs
Christian Reid, 340B Program Director
(401) 770-2118
Signed By Date
10/7/2020
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