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MISSOURI CVS PHARMACY, L.L.C.
DSH260104 SSM HEALTH DEPAUL HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH DEPAUL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260104
Entity Address
12303 DePaul Dr
BRIDGETON, MO 63044
Medicare Provider Number
260104
Participating Start Date
10/1/2006
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 10134
801 HIGHWAY K
O FALLON, MO 63366
Pharmacy Comments
Contract Details
Approval Date
1/15/2021
Contract Begin Date
1/26/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219
Contract Pharmacy Representative
cvs
Christian Reid, 340B Program Director
(401) 770-2118
Signed By Date
1/15/2021
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