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THEODOSIA PHARMACY
DSH260078 Ozarks Medical Center DBA Ozarks Healthcare
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Covered Entity Details
Entity Name
Ozarks Medical Center DBA Ozarks Healthcare
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260078
Entity Address
1100 KENTUCKY AVENUE
WEST PLAINS, MO 65775-1100
Medicare Provider Number
260078
Participating Start Date
1/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
THEODOSIA PHARMACY
Pharmacy Address
4900 US HIGHWAY 160
STE 1
THEODOSIA, MO 65761
Pharmacy Comments
Contract Details
Approval Date
9/22/2011
Contract Begin Date
9/22/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
MICHAEL GROSS, CFO
(417) 257-5837
Contract Pharmacy Representative
CRAIG ATKINS, PHARMACIST/OWNER
(417) 273-4555
Signed By Date
6/20/2011
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