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HILLCREST DRUG INC
DSH260017 PHELPS COUNTY REGIONAL MEDICAL CNTR
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Covered Entity Details
Entity Name
PHELPS COUNTY REGIONAL MEDICAL CNTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260017
Entity Address
1000 WEST 10TH STREET
ROLLA, MO 65401
Medicare Provider Number
260017
Participating Start Date
3/2/2021
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
HILLCREST DRUG INC
Pharmacy Address
1100 B SOUTH BISHOP
ROLLA, MO 65401-4418
Pharmacy Comments
Contract Details
Approval Date
4/15/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/16/2018
Ownership change
Contacts
Covered Entity Signing Official
EDWARD J. CLAYTON, Chief Executive Officer
(573) 458-7919
Contract Pharmacy Representative
John Keller, President
(573) 364-3258
Signed By Date
4/15/2013
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