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MISSOURI CVS PHARMACY, L.L.C.
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
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 10053
400 MID RIVERS MALL DR.,
ST PETERS, MO 63376
Pharmacy Comments
Contract Details
Approval Date
7/5/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Karen D. Rewerts, Regional VP of Financa/CFO
(314) 989-2034
Contract Pharmacy Representative
CVS Health
Jaclyn Parfitt, 340B Operations Manager
(401) 770-6467
Signed By Date
7/5/2016
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