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RED CROSS PHARMACY
SCH260142-01 JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
Grand River Medical Clinic
Type
Sole Community Hospital
340B ID
SCH260142-01
Entity Address
815 E. Broadway
Brunswick, MO 65236
Medicare Provider Number
260142
Outpatient Facility Provider Number
Participating Start Date
10/1/2019
Last Recertification Date
Entity Termination Date
1/1/2020
Pharmacy Details
Pharmacy Name
RED CROSS PHARMACY
Pharmacy Address
941 S CHEROKEE
STE #1
MARSHALL, MO 65340
Pharmacy Comments
Contract Details
Approval Date
12/8/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Ronald A. Ott, President & CEO
(660) 831-3249
Contract Pharmacy Representative
Red Cross Pharmacy
Scott Hartwig, CEO
(660) 886-5535
Signed By Date
12/8/2014
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