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PRESCRIPTION DRUG STORE 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
PRESCRIPTION DRUG STORE LLC
Pharmacy Address
PRESCRIPTION DRUG STORE #1
410 WARD AVE
CARUTHERSVILLE, MO 63830
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/20/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
KERRY L. NOBLE, CEO
(573) 359-3612
Contract Pharmacy Representative
Prescription Drug Store LCC
SHANE DUDLEY, DIRECTOR OF PHARMACY - MANAGER
(573) 333-4890
Signed By Date
4/15/2016
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