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SUPER D DRUGS ACQUISITION CO.
DSH260113 MISSOURI DELTA MEDICAL CENTER
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Covered Entity Details
Entity Name
MISSOURI DELTA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260113
Entity Address
1008 NORTH MAIN
SIKESTON, MO 63801
Medicare Provider Number
260113
Participating Start Date
7/1/2006
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SUPER D DRUGS ACQUISITION CO.
Pharmacy Address
DBA: WALGREENS #15800
904 W. HWY BUSINESS 60
DEXTER, MO 63841
Pharmacy Comments
Contract Details
Approval Date
10/9/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JASON SCHRUMPF, CEO
(573) 472-7600
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/9/2015
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