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MERCY PHARMACY SERVICES, LLC
DSH260059 Mercy Hospital Lebanon
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Covered Entity Details
Entity Name
Mercy Hospital Lebanon
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260059
Entity Address
100 HOSPITAL DRIVE
LEBANON, MO 65536-2263
Medicare Provider Number
260059
Participating Start Date
4/1/2007
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
MERCY PHARMACY SERVICES, LLC
Pharmacy Address
D/B/A MERCY PHARMACY ROLLA
1605 MARTIN SPRINGS DR.
STE 220
ROLLA, MO 65401
Pharmacy Comments
Contract Details
Approval Date
10/10/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DOUGLAS HOBAN, CHIEF FINANCIAL OFFICER
(417) 533-6048
Contract Pharmacy Representative
Mercy
Mark J Jaeger, VP-Ambulatory & Specialty Pharmacy
(314) 628-5607
Signed By Date
10/10/2017
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