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STEPHENS 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
STEPHENS PHARMACY
Pharmacy Address
1100 SO SPRINGFIELD
BOLIVAR, MO 65613
Pharmacy Comments
Contract Details
Approval Date
4/8/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Donald J. Babb, Chief Executive Officer
(417) 328-6501
Contract Pharmacy Representative
Michael Stephens, Owner
(417) 326-2416
Signed By Date
4/8/2016
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