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HOMETOWN PHARMACY MARSHALL
DSH260142C JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
JOHN FITZGIBBON MEM HOSPITAL INC - Fitzgibbon Family Health
Type
Disproportionate Share Hospital
340B ID
DSH260142C
Entity Address
600 W MORRISON ST
STE 5
FAYETTE, MO 65248-1075
Medicare Provider Number
260142
Outpatient Facility Provider Number
268731
Participating Start Date
4/1/2022
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
HOMETOWN PHARMACY MARSHALL
Pharmacy Address
452 W ARROW ST
MARSHALL, MO 65340-1905
Pharmacy Comments
Contract Details
Approval Date
1/11/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/28/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Angy P. Littrell, President & CEO
(660) 831-3251
Contract Pharmacy Representative
Hometown Pharmacy
Ted Groethe, Owner
(913) 530-2238
Signed By Date
1/11/2023
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