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MEDICENTER PHARMACY
CH074020 CROSS TRAILS MEDICAL CENTER
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Covered Entity Details
Entity Name
CROSS TRAILS MEDICAL CENTER
Subdivision Name
CROSS TRAILS MEDICAL CENTER
Type
HRSA-Funded Health Center
340B ID
CH074020
Entity Address
408 S Broadview St
Cape Girardeau, MO 63703-5725
Grant Number
H80CS00211
Participating Start Date
10/1/1998
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
MEDICENTER PHARMACY
Pharmacy Address
JACKSON PHARMACY INC
200 W. WASHINGTON ST.
JACKSON, MO 63755
Pharmacy Comments
Contract Details
Approval Date
11/20/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ron Camp, CEO
(573) 339-1196
Contract Pharmacy Representative
Tina Hart, Pharmacist
(573) 243-1303
Signed By Date
10/9/2012
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