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SCHNUCKS PHARMACY #399
DSH260105 SSM HEALTH SAINT LOUIS UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH SAINT LOUIS UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260105
Entity Address
1201 South Grand Blvd.
ST. LOUIS, MO 63104
Medicare Provider Number
260105
Participating Start Date
4/1/2016
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
SCHNUCKS PHARMACY #399
Pharmacy Address
12921 ENTERPRISE WAY
BRIDGETON, MO 63044-1206
Pharmacy Comments
Contract Details
Approval Date
10/15/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/8/2019
Ownership change
Contacts
Covered Entity Signing Official
Karen D. Rewerts, Regional VP of Financa/CFO
(314) 989-2034
Contract Pharmacy Representative
Schnucks
Bob Buganski, Director Pharmacy Operations
(314) 994-2226
Signed By Date
10/15/2017
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