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Walgreens Central Fill #21394
DSH260011 SSM HEALTH-ST. MARYS-JEFFERSON CITY
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Covered Entity Details
Entity Name
SSM HEALTH-ST. MARYS-JEFFERSON CITY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260011
Entity Address
2505 Mission Drive
JEFFERSON CITY, MO 65109
Medicare Provider Number
260011
Participating Start Date
7/1/2022
Last Recertification Date
9/1/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
Walgreens Central Fill #21394
Pharmacy Address
2601 Hughes Road
Suite 103
Liberty, MO 64068
Pharmacy Comments
Contract Details
Approval Date
10/11/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Shasta Manuel, VP of Finance CFO
(405) 272-7282
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/11/2023
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