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MOUNTAIN GROVE PHARMACY
DSH260024 TEXAS COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
TEXAS COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260024
Entity Address
1333 S SAM HOUSTON BLVD
HOUSTON, MO 65483
Medicare Provider Number
260024
Participating Start Date
4/1/2010
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
MOUNTAIN GROVE PHARMACY
Pharmacy Address
106 N UNION
MOUNTAIN GROVE, MO 65711
Pharmacy Comments
10/18/11 Changed zipcode from 65771 (EMG)
Contract Details
Approval Date
1/12/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
LINDA PAMPERIEN, CFO
(417) 967-1255
Contract Pharmacy Representative
Mountain Grove Pharmacy
Chris Coffman, Owner
(417) 926-9655
Signed By Date
1/12/2018
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