Contract Pharmacy Details

BYRD-WATSON TIMES SQUARE DRUG
RRC140046-00 GOOD SAMARITAN REGIONAL HEALTH CTR.

Covered Entity Details

Entity Name

GOOD SAMARITAN REGIONAL HEALTH CTR.

Subdivision Name

Type

Rural Referral Center

340B ID

RRC140046-00

Entity Address

1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864

Medicare Provider Number

140046

Participating Start Date

10/1/2015

Last Recertification Date

9/14/2022

Entity Termination Date

7/1/2023

Pharmacy Details

Pharmacy Name

BYRD-WATSON TIMES SQUARE DRUG

Pharmacy Address

3401 BROADWAY ST
MOUNT VERNON, IL 62864-2201

Pharmacy Comments

Contract Details

Approval Date

Contract Begin Date

7/1/2025

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Eileen Lamm, Regional Vice President-Finance
(314) 994-6219

Contract Pharmacy Representative

ByrdWatson
Adam Breeze, Corporation Officer
(618) 244-5400 Ext: 129

Signed By Date

4/14/2025

340B Drug Pricing Program Database