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US SPECIALTY CARE LLC
CAH261333-00 Pike County Memorial Hospital
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Covered Entity Details
Entity Name
Pike County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261333-00
Entity Address
2305 Georgia Street
Louisiana, MO 63353
Medicare Provider Number
261333
Participating Start Date
7/1/2012
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
US SPECIALTY CARE LLC
Pharmacy Address
DBA HEALTHDYNE SPECIALTY / WELLDYNE SPEC
500 EAGLES LANDING DR STE A
LAKELAND, FL 33810
Pharmacy Comments
Contract Details
Approval Date
7/12/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/5/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Justin Selle, Chief Executive Officer
(573) 754-5531 Ext: 103
Contract Pharmacy Representative
Marlette Oelofsen, Pharmacist
(800) 641-8475
Signed By Date
7/12/2016
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