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MERCY PHARMACY SERVICES, LLC
RRC260110-00 SOUTHEASTHEALTH dba MERCY HOSPITAL SOUTHEAST
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Covered Entity Details
Entity Name
SOUTHEASTHEALTH dba MERCY HOSPITAL SOUTHEAST
Subdivision Name
Type
Rural Referral Center
340B ID
RRC260110-00
Entity Address
1701 LACEY STREET
CAPE GIRARDEAU, MO 63701
Medicare Provider Number
260110
Participating Start Date
10/1/2023
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
MERCY PHARMACY SERVICES, LLC
Pharmacy Address
DBA: MERCY PHARMACY BROADWAY
1723 BROADWAY ST STE 110
CAPE GIRARDEAU, MO 63701
Pharmacy Comments
Contract Details
Approval Date
7/8/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Krista B Berry, Chief Financial Officer
(573) 331-6028
Contract Pharmacy Representative
Mercy
Mark J Jaeger, VP-Ambulatory & Specialty Pharmacy
(314) 628-5607
Signed By Date
7/8/2024
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