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BYRD-WATSON TIMES SQUARE DRUG
RRC140046-00 GOOD SAMARITAN REGIONAL HEALTH CTR.
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Covered Entity Details
Entity Name
GOOD SAMARITAN REGIONAL HEALTH CTR.
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140046-00
Entity Address
1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864
Medicare Provider Number
140046
Participating Start Date
10/1/2015
Last Recertification Date
9/14/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
BYRD-WATSON TIMES SQUARE DRUG
Pharmacy Address
3401 BROADWAY ST
MOUNT VERNON, IL 62864-2201
Pharmacy Comments
Contract Details
Approval Date
7/27/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219
Contract Pharmacy Representative
ByrdWatson
Adam Breeze, Corporation Officer
(618) 244-5400 Ext: 129
Signed By Date
7/27/2022
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