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MISSOURI CVS PHARMACY, L.L.C.
DSH260142E JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
JOHN FITZGIBBON MEMORIAL HOSP INC - Mid-Missouri Family Health
Type
Disproportionate Share Hospital
340B ID
DSH260142E
Entity Address
2303 S HIGHWAY 65 STE A
MID MISSOURI FAMILY HEALTH AT FITZG
MARSHALL, MO 65340-3735
Medicare Provider Number
260142
Outpatient Facility Provider Number
268789
Participating Start Date
1/1/2024
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #11317
227 S BROADWAY
SALISBURY, MO 65281
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
CVS Health
Gina Lohr, 340B Regional Director
(401) 537-8808
Signed By Date
10/5/2023
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