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PRIME THERAPEUTICS SPECIALTY PHARMACY LL
DSH260011 SSM HEALTH-ST. MARYS-JEFFERSON CITY
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Covered Entity Details
Entity Name
SSM HEALTH-ST. MARYS-JEFFERSON CITY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260011
Entity Address
2505 Mission Drive
JEFFERSON CITY, MO 65109
Medicare Provider Number
260011
Participating Start Date
7/1/2022
Last Recertification Date
9/1/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
PRIME THERAPEUTICS SPECIALTY PHARMACY LL
Pharmacy Address
ALLIANCERX WALGREENS PRIME #16568
2354 COMMERCE PARK DRIVE
SUITE 100
ORLANDO, FL 32819-9992
Pharmacy Comments
Contract Details
Approval Date
7/1/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/31/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Karen D. Rewerts, System VP of Finance
(557) 203-3614
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/1/2022
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