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SSM HEALTH PHARMACY
DSH140046 SSM HEALTH GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140046
Entity Address
1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864
Medicare Provider Number
140046
Participating Start Date
7/1/2023
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
SSM HEALTH PHARMACY
Pharmacy Address
1211 FISH HATCHERY RD STE 300
MADISON, WI 53715
Pharmacy Comments
Contract Details
Approval Date
6/5/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219
Contract Pharmacy Representative
SSM Health
Eric Huckins, Pharmacy Manager
(608) 824-2682
Signed By Date
4/18/2023
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