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MISSOURI CVS PHARMACY, L.L.C.
SCH260097-00 WESTERN MISSOURI MEDICAL CENTER
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Covered Entity Details
Entity Name
WESTERN MISSOURI MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH260097-00
Entity Address
403 BURKARTH ROAD
WARRENSBURG, MO 64093
Medicare Provider Number
260097
Participating Start Date
10/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08557
1900 N.E. LANGSFORD RD.
LEES SUMMIT, MO 64063
Pharmacy Comments
Contract Details
Approval Date
1/19/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dean Ohmart, Chief Financial Officer
(660) 262-7307
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/19/2021
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