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SSM HEALTH PHARMACY
DSH260104 SSM HEALTH DEPAUL HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH DEPAUL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260104
Entity Address
12303 DePaul Dr
BRIDGETON, MO 63044
Medicare Provider Number
260104
Participating Start Date
10/1/2006
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
SSM HEALTH PHARMACY
Pharmacy Address
SSM HEALTH PHARMACY LLC
12266 DE PAUL DR STE 105
BRIDGETON, MO 63044-2541
Pharmacy Comments
Contract Details
Approval Date
9/13/2011
Contract Begin Date
9/19/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/6/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lee Bernstein, Chief Operating Officer
(636) 947-5038
Contract Pharmacy Representative
Dave Wachter, Director of Pharmacy
(314) 523-8775
Signed By Date
9/19/2011
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