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CITIZENS MEMORIAL HEALTH CARE FOUNDATION
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
CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Pharmacy Address
STEPHENS PHARMACY AT CMH
1100 S SPRINGFIELD AVE
BOLIVAR, MO 65613-2512
Pharmacy Comments
Contract Details
Approval Date
7/11/2017
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
Citizens Memorial Health Care Foundation
Donald Babb, Chief Executive Officer
(417) 328-6501
Signed By Date
7/11/2017
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