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PROCARE PHARMACY, L.L.C.
CAH261301-00 ELLETT MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
ELLETT MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261301-00
Entity Address
610 NORTH OHIO AVENUE
Appleton City, MO 64724
Medicare Provider Number
261301
Participating Start Date
7/1/2016
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203
Pharmacy Comments
Contract Details
Approval Date
7/12/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Laura Ninette Smith, CEO
(660) 476-5211
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/12/2021
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