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ALPS LONG TERM CARE 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
ALPS LONG TERM CARE PHARMACY
Pharmacy Address
105 S RIDGECREST AVE STE 2
NIXA, MO 65714
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
Alps SPecialty Pharmacy
Morgan Miller, Pharmacy PIC
(417) 719-4510
Signed By Date
10/4/2021
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