Contract Pharmacy Details

SCHNUCK MARKETS
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

SCHNUCK MARKETS

Pharmacy Address

D.B.A. SCHNUCKS PHARMACY #733
1129 W. BROADWAY
CENTRALIA, IL 62801

Pharmacy Comments

Contract Details

Approval Date

1/9/2017

Contract Begin Date

4/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/12/2021
Pharmacy closed

Contacts

Covered Entity Signing Official

MICHAEL WARREN, PRESIDENT
(618) 899-1002

Contract Pharmacy Representative

Schnuck's Pharmacy
David Chism, Director of Pharmacy
(314) 344-9636

Signed By Date

1/9/2017

340B Drug Pricing Program Database