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ONCOMED THE ONCOLOGY PHARMACY OF PHILADE
DSH260017A PHELPS COUNTY REGIONAL MEDICAL CNTR
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Covered Entity Details
Entity Name
PHELPS COUNTY REGIONAL MEDICAL CNTR
Subdivision Name
PHELPS HEALTH - ONCOLOGY SERVICES
Type
Disproportionate Share Hospital
340B ID
DSH260017A
Entity Address
1060 West 10th Street
Rolla, MO 65401
Medicare Provider Number
260017
Outpatient Facility Provider Number
Participating Start Date
3/2/2021
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
ONCOMED THE ONCOLOGY PHARMACY OF PHILADE
Pharmacy Address
LLC DBA ONCO360
1553 CHESTER PIKE SUITE 206
CRUM LYNNE, PA 19022
Pharmacy Comments
Contract Details
Approval Date
7/12/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/13/2016
Pharmacy closed
Contacts
Covered Entity Signing Official
EDWARD J. CLAYTON, Chief Executive Officer
(573) 458-7919
Contract Pharmacy Representative
Burt Zweigenhaft, CEO
(646) 356-7709
Signed By Date
7/12/2013
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