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MICHELLE'S PHARMACY, INC
CAH141347-00 CARLINVILLE AREA HOSPITAL
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Covered Entity Details
Entity Name
CARLINVILLE AREA HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141347-00
Entity Address
20733 NORTH BROAD STREET
CARLINVILLE, IL 62626
Medicare Provider Number
141347
Participating Start Date
7/1/2017
Last Recertification Date
9/17/2024
Pharmacy Details
Pharmacy Name
MICHELLE'S PHARMACY, INC
Pharmacy Address
274 N BROAD ST
CARLINVILLE, IL 62626-1371
Pharmacy Comments
Contract Details
Approval Date
10/17/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/8/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael J. Brown, Chief Financial Officer
(217) 854-3857
Contract Pharmacy Representative
Michelle's Pharmacy, Inc.
Michelle Dyer, President
(618) 585-1293
Signed By Date
10/17/2017
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