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VANDIVORT DRUG (WISDOM DRUG LLC)
CAH261318-00 SALEM MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SALEM MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261318-00
Entity Address
35629 HIGHWAY 72
SALEM, MO 65560-0774
Medicare Provider Number
261318
Participating Start Date
1/1/2011
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
VANDIVORT DRUG (WISDOM DRUG LLC)
Pharmacy Address
117 W 4TH ST
SALEM, MO 65560-1255
Pharmacy Comments
Contract Details
Approval Date
10/14/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KASEY LUCAS, ADMINISTRATOR/CEO
(573) 729-5917 Ext: 4000
Contract Pharmacy Representative
wisdom drug
Teel Wisdom, owner
(573) 729-4114
Signed By Date
10/14/2020
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