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PRAIRIE MEDICAL PHARMACY
CAH141346-00 Sarah Bush Lincoln Fayette County Hospital
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Covered Entity Details
Entity Name
Sarah Bush Lincoln Fayette County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141346-00
Entity Address
650 W. Taylor Street
VANDALIA, IL 62471
Medicare Provider Number
141346
Participating Start Date
1/1/2023
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
PRAIRIE MEDICAL PHARMACY
Pharmacy Address
1000 HEALTH CENTER DRIVE
MATTOON, IL 61938
Pharmacy Comments
Contract Details
Approval Date
1/16/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Karen Ann Dyer, CEO
(618) 283-5400
Contract Pharmacy Representative
Sarah Bush Lincoln Health Center
Matthew Wade Clifton, Director of Pharmacy
(217) 258-2520
Signed By Date
1/16/2025
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