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MISSOURI CVS PHARMACY, L.L.C.
DSH260175 GOLDEN VALLEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
GOLDEN VALLEY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260175
Entity Address
1600 NORTH SECOND
CLINTON, MO 64735-1192
Medicare Provider Number
260175
Participating Start Date
10/1/2021
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 10152
1501 E. OHIO ST.
CLINTON, MO 64735
Pharmacy Comments
Contract Details
Approval Date
8/9/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tammy Nadler, CFO
(660) 890-7105
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/15/2021
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