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MISSOURI CVS PHARMACY, L.L.C.
DSH170040 UNIVERSITY OF KANSAS HOSPITAL
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Covered Entity Details
Entity Name
UNIVERSITY OF KANSAS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH170040
Entity Address
4000 Cambridge Street
Kansas City, KS 66160
Medicare Provider Number
170040
Participating Start Date
10/1/2000
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05691
11115 E US HWY 24 HWY
INDEPENDENCE, MO 64054
Pharmacy Comments
Contract Details
Approval Date
4/8/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/21/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Rick Couldry, Vice-President, Pharmacy and Clinical Professions
(913) 588-2301
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/8/2022
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