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LAKELAND PHARMACY LTC INC
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
LAKELAND PHARMACY LTC INC
Pharmacy Address
DBA PRONTO PHARMACY #5
501 SOUTH MADISON AVE., SUITE S
WEBB CITY, MO 64870
Pharmacy Comments
Contract Details
Approval Date
4/13/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
STEVE GRADDY, CFO
(417) 347-6678
Contract Pharmacy Representative
Michael Stuart, Owner/President
(417) 272-8064
Signed By Date
4/13/2017
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