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SCHNUCKS PHARMACY #399
DSH260104 SSM HEALTH DEPAUL HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH DEPAUL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260104
Entity Address
12303 DePaul Dr
BRIDGETON, MO 63044
Medicare Provider Number
260104
Participating Start Date
10/1/2006
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
10/12/2021
Pharmacy closed
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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