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MERCY PHARMACY CLARKSON VALLEY
DSH260020 MERCY HOSPITAL - ST. LOUIS
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Covered Entity Details
Entity Name
MERCY HOSPITAL - ST. LOUIS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260020
Entity Address
615 S. NEW BALLAS ROAD
Main Hospital Pharmacy and JFK Clinic
ST. LOUIS, MO 63141
Medicare Provider Number
260020
Participating Start Date
4/1/2017
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
MERCY PHARMACY CLARKSON VALLEY
Pharmacy Address
MERCY HEALTH SERVICE LLC
15945 CLAYTON ROAD
SUITE 140
BALLWIN, MO 63011-2146
Pharmacy Comments
Contract Details
Approval Date
7/17/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey A. Johnston, President
(314) 251-1932
Contract Pharmacy Representative
Mercy
Patrick Berry, Executive Director Retail Pharmacy Services
(314) 628-5606
Signed By Date
7/17/2017
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