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FOREST CITY MEDICAL CTR PHARM
DSH260017 PHELPS COUNTY REGIONAL MEDICAL CNTR
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Covered Entity Details
Entity Name
PHELPS COUNTY REGIONAL MEDICAL CNTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260017
Entity Address
1000 WEST 10TH STREET
ROLLA, MO 65401
Medicare Provider Number
260017
Participating Start Date
3/2/2021
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
FOREST CITY MEDICAL CTR PHARM
Pharmacy Address
1000 B N JEFFERSON
ST JAMES, MO 65559
Pharmacy Comments
Contract Details
Approval Date
1/11/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/31/2025
Pharmacy closed
Contacts
Covered Entity Signing Official
Jana Cook, Chief Financial Officer
(573) 458-7916
Contract Pharmacy Representative
6turtles llc
Timothy Wilson, Pharmacist In Charge
(573) 265-5400
Signed By Date
1/11/2024
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