Contract Pharmacy Details

MISSOURI CVS PHARMACY, L.L.C.
DSH260011 SSM HEALTH-ST. MARYS-JEFFERSON CITY

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

Pharmacy Details

Pharmacy Name

MISSOURI CVS PHARMACY, L.L.C.

Pharmacy Address

CVS PHARMACY # 16228
735 W STADIUM BLVD
JEFFERSON CITY, MO 65109

Pharmacy Comments

Contract Details

Approval Date

1/25/2021

Contract Begin Date

4/1/2021

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

cvs
Christian Reid, 340B Program Director
(401) 770-2118

Signed By Date

1/14/2021

340B Drug Pricing Program Database