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MERCY HOME INFUSION SPRINGFIELD
DSH260059 Mercy Hospital Lebanon
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Covered Entity Details
Entity Name
Mercy Hospital Lebanon
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260059
Entity Address
100 HOSPITAL DRIVE
LEBANON, MO 65536-2263
Medicare Provider Number
260059
Participating Start Date
4/1/2007
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
MERCY HOME INFUSION SPRINGFIELD
Pharmacy Address
2115 SOUTH FREMONT
STE 5200
SPRINGFIELD, MO 65804
Pharmacy Comments
Contract Details
Approval Date
7/12/2017
Contract Begin Date
10/1/2017
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
DOUGLAS HOBAN, CHIEF FINANCIAL OFFICER
(417) 533-6048
Contract Pharmacy Representative
Mercy
Patrick Berry, Executive Director Retail Pharmacy Services
(314) 628-5606
Signed By Date
7/12/2017
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