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MISSOURI CVS PHARMACY, L.L.C.
RRC260110-00 SOUTHEASTHEALTH dba MERCY HOSPITAL SOUTHEAST
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Covered Entity Details
Entity Name
SOUTHEASTHEALTH dba MERCY HOSPITAL SOUTHEAST
Subdivision Name
Type
Rural Referral Center
340B ID
RRC260110-00
Entity Address
1701 LACEY STREET
CAPE GIRARDEAU, MO 63701
Medicare Provider Number
260110
Participating Start Date
10/1/2023
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #10256
2161 WILLIAM ST.
CAPE GIRARDEAU, MO 63703
Pharmacy Comments
Contract Details
Approval Date
4/14/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Hubert U. King, CFO
(573) 651-5500 Ext: 5893
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
4/14/2014
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