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COUNTRYSIDE PHARMACY
CH072130 NORTHWEST HEALTH SERVICES, INC.
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Covered Entity Details
Entity Name
NORTHWEST HEALTH SERVICES, INC.
Subdivision Name
FAMILY MEDICINE ASSOCIATES
Type
HRSA-Funded Health Center
340B ID
CH072130
Entity Address
2303 Village Dr
Saint Joseph, MO 64506-4954
Grant Number
H80CS00671
Participating Start Date
10/1/1997
Last Recertification Date
2/19/2025
Pharmacy Details
Pharmacy Name
COUNTRYSIDE PHARMACY
Pharmacy Address
402 E PRICE AVE
P.O. BOX 147
SAVANNAH, MO 64485-1742
Pharmacy Comments
Contract Details
Approval Date
7/27/2011
Contract Begin Date
7/27/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/21/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
6/29/2011
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