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MISSOURI CVS PHARMACY, L.L.C.
DSH260105 SSM HEALTH SAINT LOUIS UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH SAINT LOUIS UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260105
Entity Address
1201 South Grand Blvd.
ST. LOUIS, MO 63104
Medicare Provider Number
260105
Participating Start Date
4/1/2016
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
CVS/PHARMACY # 10025
400 S. TRUMAN BLVD.
CRYSTAL CITY, MO 63019
Pharmacy Comments
Contract Details
Approval Date
10/17/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219
Contract Pharmacy Representative
CVS
Charles Basralian, Acct Manager
(401) 772-7343
Signed By Date
10/17/2022
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