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MISSOURI CVS PHARMACY, L.L.C.
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
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #10280
500 N BISHOP AVENUE
ROLLA, MO 65401-2989
Pharmacy Comments
Contract Details
Approval Date
4/12/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KASEY LUCAS, ADMINISTRATOR/CEO
(573) 729-5917 Ext: 4000
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/12/2021
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