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SSM MEDICAL GROUP INC (SSM HEALTH PHARMA
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
SSM MEDICAL GROUP INC (SSM HEALTH PHARMA
Pharmacy Address
711 VETERANS MEMORIAL PKWY STE 102
SAINT CHARLES, MO 63303-2106
Pharmacy Comments
Contract Details
Approval Date
10/17/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Karen D. Rewerts, System VP of Finance
(557) 203-3614
Contract Pharmacy Representative
SSM Health
Eric Huckins, Pharmacy Manager
(608) 824-2682
Signed By Date
10/17/2022
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