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MITCHELL'S DRUG STORES ON THE BOULEVARD
DSH260137 FREEMAN HEALTH SYSTEM
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Covered Entity Details
Entity Name
FREEMAN HEALTH SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260137
Entity Address
1102 WEST 32ND STREET
JOPLIN, MO 64804-3503
Medicare Provider Number
260137
Participating Start Date
4/1/2004
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
MITCHELL'S DRUG STORES ON THE BOULEVARD
Pharmacy Address
TIM MITCHELL MEDICAL INC
719 S. NEOSHO BLVD
SUITE A
NEOSHO, MO 64850-2007
Pharmacy Comments
Contract Details
Approval Date
7/8/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
STEVE GRADDY, CFO
(417) 347-6678
Contract Pharmacy Representative
Tim Mitchell, Owner
(417) 451-9501
Signed By Date
7/8/2016
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