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CLARK'S RX FARMINGTON LLC
CAH261336-00 IRON COUNTY HOSPITAL
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Covered Entity Details
Entity Name
IRON COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261336-00
Entity Address
301 NORTH HWY 21
PILOT KNOB, MO 63663
Medicare Provider Number
261336
Participating Start Date
10/1/2016
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
CLARK'S RX FARMINGTON LLC
Pharmacy Address
CLARK'S RX
124 W RUSSELL STREET
IRONTON, MO 63650
Pharmacy Comments
Contract Details
Approval Date
7/5/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2018
Ownership change
Contacts
Covered Entity Signing Official
Terry W. Nichols, Chief Executive Officer
(573) 546-8003
Contract Pharmacy Representative
Rebecca Nugent, General Manager
(937) 428-7970
Signed By Date
7/5/2017
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