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MISSOURI CVS PHARMACY, L.L.C.
CAH261332-00 Carroll County Memorial Hospital
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Covered Entity Details
Entity Name
Carroll County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261332-00
Entity Address
1502 N Jefferson
Carrollton, MO 64633
Medicare Provider Number
261332
Participating Start Date
4/1/2013
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #11316
941 CHEROKEE DR STE 1
MARSHALL, MO 65340
Pharmacy Comments
Contract Details
Approval Date
4/4/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/30/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Charles Blake Riley, Chief Operations Officer
(660) 542-1695 Ext: 3972
Contract Pharmacy Representative
Carroll County Memorial Hospital
Carson Josephine Pyle, Pharmacy 340B Cordinator
(660) 542-1695 Ext: 3617
Signed By Date
4/4/2023
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