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HERMITAGE PROFESS PHARMACY
DSH260195 CITIZENS MEMORIAL HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
CITIZENS MEMORIAL HOSPITAL DISTRICT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260195
Entity Address
1500 NORTH OAKLAND
BOLIVAR, MO 65613
Medicare Provider Number
260195
Participating Start Date
4/1/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
HERMITAGE PROFESS PHARMACY
Pharmacy Address
23649 DALLAS ST
P.O.BOX 370
HERMITAGE, MO 65668
Pharmacy Comments
Contract Details
Approval Date
8/22/2012
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Donald J. Babb, Chief Executive Officer
(417) 328-6501
Contract Pharmacy Representative
Hermitage Professional Pharmacy
Alvin L. Nyberg, Pharmacist-In-Charge
(417) 345-2321
Signed By Date
7/4/2012
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