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AVELLA OF ST LOUIS
DSH260011 SSM HEALTH-ST. MARYS-JEFFERSON CITY
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Covered Entity Details
Entity Name
SSM HEALTH-ST. MARYS-JEFFERSON CITY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260011
Entity Address
2505 Mission Drive
JEFFERSON CITY, MO 65109
Medicare Provider Number
260011
Participating Start Date
7/1/2022
Last Recertification Date
9/1/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
AVELLA OF ST LOUIS
Pharmacy Address
450 N NEW BALLAS RD STE 256
SAINT LOUIS, MO 63141-6836
Pharmacy Comments
Contract Details
Approval Date
1/25/2021
Contract Begin Date
1/25/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Becky Miller, Vice President-Hospital Operations
(573) 681-3136
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/14/2021
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