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MEDICINE SHOPPE OF SALEM INC
CAH141345-00 Salem Township Hospital
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Covered Entity Details
Entity Name
Salem Township Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141345-00
Entity Address
1201 Ricker Drive
Salem, IL 62881
Medicare Provider Number
141345
Participating Start Date
4/1/2013
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
MEDICINE SHOPPE OF SALEM INC
Pharmacy Address
MLM PHARMACY INC
215 N BROADWAY AVE
SALEM, IL 62881-1511
Pharmacy Comments
Contract Details
Approval Date
10/18/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/29/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Stephanie Hilton-Siebert, President/CEO
(618) 548-3194 Ext: 8257
Contract Pharmacy Representative
Craig M. Morton, Owner PIC
(618) 548-0070
Signed By Date
10/18/2013
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