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WAL-MART PHARMACY 10-1188
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
WAL-MART PHARMACY 10-1188
Pharmacy Address
11900 ST CHARLES ROCK RD
BRIDGETON, MO 63044
Pharmacy Comments
Contract Details
Approval Date
10/5/2016
Contract Begin Date
1/1/2017
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
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/5/2016
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