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HOMETOWN PHARMACY
CAH261332-00 Carroll County Memorial Hospital
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Covered Entity Details
Entity Name
Carroll County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261332-00
Entity Address
1502 N Jefferson
Carrollton, MO 64633
Medicare Provider Number
261332
Participating Start Date
4/1/2013
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
HOMETOWN PHARMACY
Pharmacy Address
1409 N JEFFERSON ST
CARROLLTON, MO 64633-1945
Pharmacy Comments
Contract Details
Approval Date
4/1/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/15/2023
Ownership change
Contacts
Covered Entity Signing Official
Shannon Jordan, COO
(660) 542-1695 Ext: 3002
Contract Pharmacy Representative
Hometown Pharmacy
Ted Groethe, Owner
(913) 530-2238
Signed By Date
4/1/2013
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