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KB KIRKSVILLE PHARMACY LLC
SCH260025-00 HANNIBAL REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
HANNIBAL REGIONAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH260025-00
Entity Address
6000 HOSPITAL DRIVE
HANNIBAL, MO 63401
Medicare Provider Number
260025
Participating Start Date
10/1/2023
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
KB KIRKSVILLE PHARMACY LLC
Pharmacy Address
1611 S BALTIMORE ST STE B
KIRKSVILLE, MO 63501-4536
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
Rob Gasaway, VP-Finance/CFO
(573) 406-1608
Contract Pharmacy Representative
Evans Drugs
Kevin McCullough, Owner
(417) 876-3313
Signed By Date
7/8/2024
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