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GREENFIELD PHARMACY
SCH260195-00 CITIZENS MEMORIAL HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
CITIZENS MEMORIAL HOSPITAL DISTRICT
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH260195-00
Entity Address
1500 NORTH OAKLAND
BOLIVAR, MO 65613
Medicare Provider Number
260195
Participating Start Date
11/1/2021
Last Recertification Date
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
GREENFIELD PHARMACY
Pharmacy Address
FREEZE PHARMACY LLC
105 N GRAND ST STE 1
GREENFIELD, MO 65661-8198
Pharmacy Comments
Contract Details
Approval Date
11/1/2021
Contract Begin Date
11/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Renee Marie Meyer, Chief Financial Officer
(417) 328-6258
Contract Pharmacy Representative
Greenfield Pharmacy
Allison Freeze, Manager
(417) 637-2909
Signed By Date
10/4/2021
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