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SAM'S HEALTH MART PHARMACY #3
DSH260142A JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
Akeman-McBurney Medical Clinic
Type
Disproportionate Share Hospital
340B ID
DSH260142A
Entity Address
420 W. Front St.
Slater, MO 65349-1328
Medicare Provider Number
260142
Outpatient Facility Provider Number
Participating Start Date
1/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
SAM'S HEALTH MART PHARMACY #3
Pharmacy Address
SAM'S PRESCRIPTION SHOP INC
300 N. CHURCH ST.
PO BOX 509
FAYETTE, MO 65248-0509
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Angy P. Littrell, President & CEO
(660) 831-3251
Contract Pharmacy Representative
Sam's Health Mart Pharmacy #3
Christian Tadrus, Officer and Pharmacist
(660) 263-3309
Signed By Date
1/17/2023
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