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MISSOURI CVS PHARMACY, L.L.C.
RRC260175-00 GOLDEN VALLEY MEMORIAL HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
GOLDEN VALLEY MEMORIAL HOSPITAL DISTRICT
Subdivision Name
Type
Rural Referral Center
340B ID
RRC260175-00
Entity Address
1600 NORTH SECOND STREET
CLINTON, MO 64735
Medicare Provider Number
260175
Participating Start Date
9/29/2010
Last Recertification Date
8/31/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 10152
1501 E. OHIO ST.
CLINTON, MO 64735
Pharmacy Comments
Contract Details
Approval Date
10/13/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Mark Mattes, CNO
(660) 890-7167
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/13/2014
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