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WAL-MART PHARMACY 10-0122
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
WAL-MART PHARMACY 10-0122
Pharmacy Address
3051 EAST JACKSON BLVD
JACKSON, MO 63755
Pharmacy Comments
Contract Details
Approval Date
10/15/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John Skeans, CFO
(573) 651-5500 Ext: 5870
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/15/2014
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