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LIBERTY 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
LIBERTY PHARMACY
Pharmacy Address
RKJ HOLDINGS LLC
508-2 W. US 60
MOUNTAIN VIEW, MO 65548
Pharmacy Comments
Contract Details
Approval Date
1/13/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/14/2016
Pharmacy closed
Contacts
Covered Entity Signing Official
Kim Thompson, CFO
(417) 256-9111 Ext: 6031
Contract Pharmacy Representative
Ron Jensen, Owner
(417) 934-0009
Signed By Date
1/13/2016
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