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KB OSCEOLA DRUG, LLC DBA EVANS DRUGS
DSH260175V GOLDEN VALLEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
GOLDEN VALLEY MEMORIAL HOSPITAL
Subdivision Name
FAMILY MEDICINE - OSCEOLA - RURAL HEALTH CLINIC IV
Type
Disproportionate Share Hospital
340B ID
DSH260175V
Entity Address
675 THIRD STREET
OSCEOLA, MO 64776
Medicare Provider Number
260175
Outpatient Facility Provider Number
Participating Start Date
10/1/2021
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
KB OSCEOLA DRUG, LLC DBA EVANS DRUGS
Pharmacy Address
675 3RD ST
PO BOX 555
OSCEOLA, MO 64776
Pharmacy Comments
Contract Details
Approval Date
1/4/2022
Contract Begin Date
1/14/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tammy Nadler, CFO
(660) 890-7105
Contract Pharmacy Representative
Evans Drugs
Kevin McCullough, Owner
(417) 876-3313
Signed By Date
1/4/2022
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