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SUMMERS PHARMACY
DSH260175M GOLDEN VALLEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
GOLDEN VALLEY MEMORIAL HOSPITAL
Subdivision Name
FAMILY MEDICINE - CLINTON RHC - RURAL HEALTH CLINIC II
Type
Disproportionate Share Hospital
340B ID
DSH260175M
Entity Address
1602 NORTH SECOND STREET
CLINTON, MO 64735
Medicare Provider Number
260175
Outpatient Facility Provider Number
Participating Start Date
10/1/2021
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
SUMMERS PHARMACY
Pharmacy Address
1602 N 2ND ST
CLINTON, MO 64735
Pharmacy Comments
Contract Details
Approval Date
1/3/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tammy Nadler, CFO
(660) 890-7105
Contract Pharmacy Representative
Summers Pharmacy
Ryan Summers, Owner
(660) 885-3034
Signed By Date
1/3/2023
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