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CVS CAREMARK
DSH260017 PHELPS COUNTY REGIONAL MEDICAL CNTR
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Covered Entity Details
Entity Name
PHELPS COUNTY REGIONAL MEDICAL CNTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260017
Entity Address
1000 WEST 10TH STREET
ROLLA, MO 65401
Medicare Provider Number
260017
Participating Start Date
3/2/2021
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
CVS CAREMARK
Pharmacy Address
DBA CVS/CAREMARK OR CF# 11506
1 GREAT VALLEY BOULEVARD
WILKES BARRE, PA 18706
Pharmacy Comments
Contract Details
Approval Date
5/18/2023
Contract Begin Date
5/24/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jana Cook, Chief Financial Officer
(573) 458-7916
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
5/18/2023
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