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CORNERSTONE PHARMACY KENNETT, LLC
DSH260070 PEMISCOT COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PEMISCOT COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260070
Entity Address
946 East Reed
HAYTI, MO 63851
Medicare Provider Number
260070
Participating Start Date
1/1/2015
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
CORNERSTONE PHARMACY KENNETT, LLC
Pharmacy Address
CORNERSTONE PHARMACY
123 1ST ST
KENNETT, MO 63857-2051
Pharmacy Comments
Contract Details
Approval Date
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DAVID KETCHUM, CEO
(573) 359-3579
Contract Pharmacy Representative
Cornerstone Pharmacy Kennett LLC
Justin Garner, Owner
(573) 888-9094
Signed By Date
7/15/2024
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