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OPTION CARE ENTERPRISES, INC.
DSH260142D JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
JOHN FITZGIBBON HOSPITAL INC - Pilot Grove Medical Clinic
Type
Disproportionate Share Hospital
340B ID
DSH260142D
Entity Address
212 COLLEGE ST
PILOT GROVE MEDICAL CLINIC AT FITZG
PILOT GROVE, MO 65276-1005
Medicare Provider Number
260142
Outpatient Facility Provider Number
268790
Participating Start Date
1/1/2024
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OPTION CARE ENTERPRISES, INC.
Pharmacy Address
OPTION CARE
1410 HERIFORD ROAD
COLUMBIA, MO 65202-1907
Pharmacy Comments
Contract Details
Approval Date
11/2/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Angy P. Littrell, President & CEO
(660) 831-3251
Contract Pharmacy Representative
Option Care
Jenny Money, Senior Manager, Health Systems Programs
(773) 202-6786
Signed By Date
10/5/2023
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