Covered Entity Details

DSH160083 CATHOLIC HEALTH INITIATIVES - IOWA, CORP (Active) - information as of 4/24/2025 10:11:27 PM

Main Details

Name

CATHOLIC HEALTH INITIATIVES - IOWA, CORP

Subdivision Name

MERCYONE DES MOINES MEDICAL CENTER

Type

Disproportionate Share Hospital

Rural

340B ID

DSH160083

Medicare Provider Number

160083

Additional Details

Current Program Status

Active

Registration Date

3/3/2011

Participating Start Date

4/1/2011

Participating Approval Date

3/15/2011

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

MercyOne
Terri Jane Donovan, Interim Chief Financial Officer
(515) 643-8212

Primary Contact

MercyOne
Jennifer Lynn Egbert, Market Director of Pharmacy
(304) 730-5888

Addresses

Street Address

1111 6th Avenue
DES MOINES, IA 50314-2610

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
IA	0600833,0600002	1508964883,1538395975
MO	011266400	1508964883,1538395975
AZ	29927	1508964883,1538395975
AR	114284105	1508964883,1538395975
CO	9000159864	1508964883,1538395975
IL	420680448001	1508964883,1538395975
NE	10026115701	1508964883,1538395975
IN	300034708	1508964883,1538395975
MS	07580863	1508964883,1538395975
CT	008106040	1508964883,1538395975
MN		1508964883,1538395975
NC		1508964883,1538395975

Shipping Addresses

Shipping Address 1

MercyOne Clive Pharmacy
1601 Northwest 114th Street Suite 234
Clive, IA 50325

Shipping Address 2

Mercyone Ankeny Pharmacy
800 East 1st Street Suite 1800
Ankeny, IA 50021

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/12/2019	10/01/2019		10/01/2019
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/12/2019	10/01/2019		10/01/2019
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/12/2019	10/01/2019		10/01/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/12/2019	10/01/2019		10/01/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/12/2019	10/01/2019		10/01/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/12/2019	10/01/2019		10/01/2019
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/10/2020	10/01/2020		10/01/2020
Contract Detail	AMBER ENTERPRISES, INC	DBA AMBER SPECIALTY PHARMACY	10004 S 152ND ST STE A	OMAHA	NE	68138-3931	07/20/2017	10/01/2017		10/01/2017
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	07/12/2019	10/01/2019	10/01/2020	10/01/2020
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	10/15/2023	01/01/2024		01/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	10/15/2023	01/01/2024		01/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	10/15/2023	01/01/2024		01/01/2024
Contract Detail	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	07/12/2019	10/01/2019	10/01/2019	04/27/2021
Contract Detail	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	07/12/2019	10/01/2019	10/01/2019	04/27/2021
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/06/2017	07/01/2017		04/06/2017
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/06/2017	07/01/2017		04/06/2017
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/06/2017	07/01/2017		04/06/2017
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/06/2017	07/01/2017		04/06/2017
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/06/2017	07/01/2017		04/06/2017
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/06/2017	07/01/2017		04/06/2017
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/06/2017	07/01/2017		04/06/2017
Contract Detail	CAREMARK PUERTO RICO SPECIALTY PHARMACY,	CAREMARK PUERTO RICO SPECIALTY PHARMACY	6020 AVE ROBERTO SANCHEZ VILELLA	CAROLINA	PR	00982	07/10/2020	10/01/2020	04/07/2022	04/07/2022
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/06/2017	07/01/2017		04/06/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/06/2017	07/01/2017		04/06/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/10/2020	10/01/2020		10/01/2020
Contract Detail	CHI HEALTH SPECIALTY PHARMACY	7710 MERCY RD STE 102		OMAHA	NE	68124-2339	04/05/2017	07/01/2017	09/30/2021	11/19/2021
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	07/14/2022	10/01/2022		10/01/2022
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/14/2022	10/01/2022		10/01/2022
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/10/2020	10/01/2020		10/01/2020
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	01/17/2018	04/01/2018		01/17/2018
Contract Detail	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	10/15/2023	01/01/2024		01/01/2024
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/08/2020	10/01/2020		10/01/2020
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	07/08/2020	10/01/2020		10/01/2020
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/08/2020	10/01/2020		10/01/2020
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/08/2020	10/01/2020		10/01/2020
Contract Detail	GENOA HEALTHCARE LLC	3809 SOUTH CENTER STREET, SUITE 100		MARSHALLTOWN	IA	50158	10/11/2024	01/01/2025		01/01/2025
Contract Detail	GENOA HEALTHCARE LLC	720 KENYON ROAD, SUITE 3		FORT DODGE	IA	50501	10/11/2024	01/01/2025		01/01/2025
Contract Detail	GRX HOLDINGS, LLC	MEDICAP PHARMACY	504 14TH STREET PO BOX 369	DALLAS CENTER	IA	50063-2075	01/16/2023	04/01/2023		04/01/2023
Contract Detail	GRX HOLDINGS, LLC	MEDICAP PHARMACY	250 SE GATEWAY DRIVE	GRIMES	IA	50111	01/16/2023	04/01/2023		04/01/2023
Contract Detail	GRX HOLDINGS, LLC DBA MEDICAP PHARMACY	212 1ST ST N		NEWTON	IA	50208	01/16/2023	04/01/2023		04/01/2023
Contract Detail	GRX HOLDINGS, LLC DBA MEDICAP PHARMACY	1602 EDGINGTON AVE		ELDORA	IA	50627	01/16/2023	04/01/2023		04/01/2023
Contract Detail	GRX HOLDINGS, LLC DBA MEDICAP PHARMACY	107 NE DELAWARE AVE STE 6		ANKENY	IA	50021-6691	01/16/2023	04/01/2023		04/01/2023
Contract Detail	HY VEE PHARMACY	1107 E ARMY POST RD		DES MOINES	IA	50315	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY VEE PHARMACY	1107 E ARMY POST RD		DES MOINES	IA	50315	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HY-VEE	DBA HY-VEE FOOD &DRUG CTR	1990 GRAND AVENUE	WEST DES MOINES	IA	50265	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE	DBA HY-VEE FOOD &DRUG CTR	1990 GRAND AVENUE	WEST DES MOINES	IA	50265	01/14/2021	04/01/2021		04/01/2021
Contract Detail	HY-VEE #1449	1501 1ST AVE. E.		NEWTON	IA	50208	01/14/2021	04/01/2021		04/01/2021
Contract Detail	HY-VEE CLINIC PHARMACY (1022)	301 S. US HWY 69		HUXLEY	IA	50124	03/14/2013	04/01/2013	04/19/2015	11/20/2015
Contract Detail	HY-VEE CLINIC PHARMACY (1022)	301 S. US HWY 69		HUXLEY	IA	50124	01/14/2021	04/01/2021		04/01/2021
Contract Detail	HY-VEE DRUGSTORE 2 PHCY #7082	1010 60TH STREET		WEST DES MOINES	IA	50266	09/24/2012	09/24/2012	04/19/2015	09/12/2022
Contract Detail	HY-VEE DRUGSTORE 2 PHCY #7082	1010 60TH STREET		WEST DES MOINES	IA	50266	01/14/2021	04/01/2021		04/01/2021
Contract Detail	HY-VEE DRUGSTORE CLINIC PHCY	1541 SE. THIRD STREET SUITE 100		GRIMES	IA	50111	03/14/2013	04/01/2013	04/19/2015	11/20/2015
Contract Detail	HY-VEE DRUGSTORE CLINIC PHCY	1541 SE. THIRD STREET SUITE 100		GRIMES	IA	50111	01/14/2021	04/01/2021	09/13/2021	10/18/2021
Contract Detail	HY-VEE DRUGSTORE PHARMACY #7031	4100 UNIVERSITY AVENUE		DES MOINES	IA	50311	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE DRUGSTORE PHARMACY #7031	4100 UNIVERSITY AVENUE		DES MOINES	IA	50311	01/14/2021	04/01/2021		04/01/2021
Contract Detail	HY-VEE FOOD & DRUG #2	HY-VEE FOOD STORES INC	2540 E EUCLID AVENUE	DES MOINES	IA	50317	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE FOOD & DRUG #2	HY-VEE FOOD STORES INC	2540 E EUCLID AVENUE	DES MOINES	IA	50317	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HY-VEE FOOD STORES	DBA HY-VEE PHARMACY	8701 DOUGLAS	URBANDALE	IA	50322	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE FOOD STORES	DBA HY-VEE PHARMACY	8701 DOUGLAS	URBANDALE	IA	50322	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HY-VEE PHACY #1136	3330 MARTIN LUTHER KING JR PKY		DES MOINES	IA	50310	03/14/2013	04/01/2013	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHACY #1136	3330 MARTIN LUTHER KING JR PKY		DES MOINES	IA	50310	01/14/2021	04/01/2021		04/01/2021
Contract Detail	HY-VEE PHARMACY	3221 SE 14TH ST		DES MOINES	IA	50320	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHARMACY	410 N ANKENY BLVD		ANKENY	IA	50023	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHARMACY	910 N. JEFFERSON		INDIANOLA	IA	50125	09/24/2012	09/24/2012	04/19/2015	09/12/2022
Contract Detail	HY-VEE PHARMACY	1725 JORDAN CREEK PARKWAY		WEST DES MOINES	IA	50266	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHARMACY	4605 FLEUR DR		DES MOINES	IA	50321	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHARMACY	1700 VALLEY WEST DR		WEST DES MOINES	IA	50266	03/14/2013	04/01/2013	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHARMACY	410 N ANKENY BLVD		ANKENY	IA	50023	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HY-VEE PHARMACY	3221 SE 14TH ST		DES MOINES	IA	50320	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HY-VEE PHARMACY	4605 FLEUR DR		DES MOINES	IA	50321	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HY-VEE PHARMACY	1725 JORDAN CREEK PARKWAY		WEST DES MOINES	IA	50266	01/14/2021	04/01/2021		04/01/2021
Contract Detail	HY-VEE PHARMACY	1700 VALLEY WEST DR		WEST DES MOINES	IA	50266	01/14/2021	04/01/2021		04/01/2021
Contract Detail	HY-VEE PHARMACY	910 N. JEFFERSON		INDIANOLA	IA	50125	01/14/2021	04/01/2021		04/01/2021
Contract Detail	HY-VEE PHARMACY (1011)	108 8TH STREET SW		ALTOONA	IA	50009	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHARMACY (1011)	108 8TH STREET SW		ALTOONA	IA	50009	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HY-VEE PHARMACY (1318)	5750 MERLE HAY ROAD BOX 9		JOHNSTON	IA	50131	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHARMACY (1318)	5750 MERLE HAY ROAD BOX 9		JOHNSTON	IA	50131	01/14/2021	04/01/2021		04/01/2021
Contract Detail	HY-VEE PHARMACY (1530)	4815 MAPLE		PLEASANT HILL	IA	50327	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHARMACY (1530)	4815 MAPLE		PLEASANT HILL	IA	50327	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HY-VEE PHARMACY 1890	555 SOUTH 51ST STREET		WEST DES MOINES	IA	50265	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHARMACY 1890	555 SOUTH 51ST STREET		WEST DES MOINES	IA	50265	01/14/2021	04/01/2021		04/01/2021
Contract Detail	HY-VEE PHARMACY 1895	HY-VEE INC.	7101 UNIVERSITY AVE	WINDSOR HEIGHTS	IA	50324	09/24/2012	09/24/2012	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHARMACY 1895	HY-VEE INC.	7101 UNIVERSITY AVE	WINDSOR HEIGHTS	IA	50324	01/14/2021	04/01/2021		04/01/2021
Contract Detail	Hy-Vee Pharmacy Fulfillment Center #4016	Hy-Vee Inc	4707 Fleur Dr	Des Moines	IA	50321	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HY-VEE PHARMACY FULFILLMENT CENTER 4016	HY-VEE INC	4707 FLUER DR	DES MOINES	IA	50321	10/28/2013	01/01/2014	04/19/2015	11/20/2015
Contract Detail	HY-VEE PHARMACY SOLUTIONS	HYVACS, LLC	10004 S 152ND ST STE C	OMAHA	NE	68138	07/20/2017	10/01/2017		10/01/2017
Contract Detail	HY-VEE, INC.	DBA: HY-VEE PHARMACY #1873	1005 EAST HICKMAN	WAUKEE	IA	50263	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HY-VEE, INC.	DBA: HY-VEE PHARMACY #2 (1023)	2510 SW STATE ST.	ANKENY	IA	50023	03/14/2013	04/01/2013	04/19/2015	11/20/2015
Contract Detail	HY-VEE, INC.	DBA: HY-VEE PHARMACY #2 (1023)	2510 SW STATE ST.	ANKENY	IA	50023	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HY-VEE, INC.	HY-VEE PHARMACY (1224)	351 NE GATEWAY DRIVE	GRIMES	IA	50111	10/18/2021	01/01/2022		01/01/2022
Contract Detail	IOWA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY #10329	2303 MERLE HAY ROAD	DES MOINES	IA	50310	04/07/2022	07/01/2022		07/01/2022
Contract Detail	IOWA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 10114	104 E. FIRST ST.	ANKENY	IA	50023	04/07/2022	07/01/2022		07/01/2022
Contract Detail	IOWA CVS PHARMACY, L.L.C.	CVS/PHARMACY #10161	215 EUCLID AVENUE	DES MOINES	IA	50313	04/07/2022	07/01/2022	10/10/2024	10/11/2024
Contract Detail	IOWA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17056	3414 8TH ST SW	ALTOONA	IA	50009	04/07/2022	07/01/2022		07/01/2022
Contract Detail	IOWA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 10480	14201 HICKMAN RD.	URBANDALE	IA	50323	04/07/2022	07/01/2022		07/01/2022
Contract Detail	IOWA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 10162	3151 SE 14TH STREET	DES MOINES	IA	50320	04/07/2022	07/01/2022	10/10/2024	10/11/2024
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS, LLC	615 E. MAIN STREET	PANORA	IA	50216-1097	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS LLC	800 SCHOOL STREET	CARLISLE	IA	50047	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS LLC	318 N LINCOLN STREET	KNOXVILLE	IA	50138	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS LLC	1300 EAST 14TH STREET	DES MOINES	IA	50316	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS, LLC	10 S. WARRIOR LANE	WAUKEE	IA	50263	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS, LLC	2527 EASTON BLVD	DES MOINES	IA	50317	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS, LLC	403 STORY STREET	BOONE	IA	50036-3533	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS LLC	2105 N 3RD LN	INDIANOLA	IA	50125	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS, LLC	904 N JOHN WAYNE DR	WINTERSET	IA	50273	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS, LLC	2301 SUNSET DR STE A	NORWALK	IA	50211	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS, LLC	2804 BEAVER AVENUE	DES MOINES	IA	50310	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS LLC	105 LINCOLN WAY	AMES	IA	50010	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	GRX HOLDINGS LLC	950 28TH AVE SW SUITE 1	ALTOONA	IA	50009-1940	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY	MEDICAP PHARMACY	8170 DOUGLAS AVE	URBANDALE	IA	50322	01/17/2023	04/01/2023		04/01/2023
Contract Detail	MEDICAP PHARMACY LTC	GRX HOLDINGS LLC	404 E. EUCLID	INDIANOLA	IA	50125-1730	01/16/2023	04/01/2023		04/01/2023
Contract Detail	MERCYONE ANKENY PHARMACY	800 E 1ST ST STE 1800		ANKENY	IA	50021-2100	07/27/2011	07/27/2011	07/31/2024	08/09/2024
Contract Detail	MERCYONE CLIVE PHARMACY	1601 NW 114TH ST STE 234		CLIVE	IA	50325-7007	07/27/2011	07/27/2011	07/31/2024	08/09/2024
Contract Detail	MERCYONE DES MOINES PHARMACY	1111 6TH AVE		DES MOINES	IA	50314-2613	07/27/2011	07/27/2011	07/31/2024	08/09/2024
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	07/12/2019	10/01/2019	02/02/2021	04/14/2021
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	10/11/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM FRONTIER THERAPIES, LLC	325 W ATHERTON RD	SUITE 1	FLINT	MI	48507-2601	10/11/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM INFUSION SERVICES 302, LLC	8720 S 114TH ST STE 106		LA VISTA	NE	68128-5585	10/11/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	10/11/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	1819 ASTON AVE STE 104		CARLSBAD	CA	92008	10/11/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	10607 & 10611 AURORA AVE.		URBANDALE	IA	50322	10/11/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	10/11/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	10/12/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/11/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	10/11/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/12/2019	10/01/2019		10/01/2019
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	10/11/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/12/2019	10/01/2019		10/01/2019
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	10/12/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	07/12/2019	10/01/2019		10/01/2019
Contract Detail	OPTUM PHARMACY 800, INC.	3016 GUADALUPE ST STE A		AUSTIN	TX	78705-2861	07/12/2019	10/01/2019		10/01/2019
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/09/2020	07/09/2020		07/22/2020
Contract Detail	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	07/15/2019	10/01/2019		10/01/2019
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	10/12/2023	01/01/2024		01/01/2024
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	01/17/2018	04/01/2018		01/17/2018
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/06/2017	07/01/2017		04/06/2017
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/10/2020	10/01/2020		10/01/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	07/10/2020	10/01/2020		10/01/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/10/2020	10/01/2020		10/01/2020
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	10/15/2023	01/01/2024		01/01/2024
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	10/15/2023	01/01/2024		01/01/2024
Contract Detail	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	10/15/2023	01/01/2024		01/01/2024
Contract Detail	ST JOSEPH'S MCAULEY PHARMACY	500 W. THOMAS ROAD	SUITE 190	PHOENIX	AZ	85013	07/08/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-0749	3105 GRAND AVENUE		AMES	IA	50010	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-0892	1002 SE NATIONAL DRIVE		ANKENY	IA	50021	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-1491	1500 NORTH JEFFERSON		INDIANOLA	IA	50125	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-1723	5101 SOUTHEAST 14TH STREET		DES MOINES	IA	50320	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-1764	1001 73RD ST		WINDSOR HEIGHTS	IA	50324-1311	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-2764	3501 8TH STREET SW		ALTOONA	IA	50009	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-2935	814 WEST BELL AVENUE		KNOXVILLE	IA	50138	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-3762	6365 STAGECOACH DRIVE		WEST DES MOINES (SW)	IA	50266	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-5748	2150 E 1ST ST		GRIMES	IA	50111	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06623	1660 22ND STREET	WEST DES MOINES	IA	50266	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 12108	2719 GRAND AVE	AMES	IA	50010	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04714	4555 FLEUR DRIVE	DES MOINES	IA	50321	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05944	6200 MERLE HAY ROAD	JOHNSTON	IA	50131	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03252	606 WALNUT STREET	DES MOINES	IA	50309	01/17/2018	04/01/2018	02/26/2024	02/26/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05942	1204 1ST AVE EAST	NEWTON	IA	50208	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05943	1000 N JEFFERSON WAY	INDIANOLA	IA	50125	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04973	7000 DOUGLAS AVE	URBANDALE	IA	50322	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03773	4600 86TH ST	URBANDALE	IA	50322	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07452	4415 DOUGLAS AVE	DES MOINES	IA	50310-2717	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05852	3030 UNIVERSITY AVE	DES MOINES	IA	50311	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06678	1999 GRAND AVE	WEST DES MOINES	IA	50265	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05362	1330 E. UNIVERSITY	DES MOINES	IA	50316	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05721	3140 SE 14TH ST	DES MOINES	IA	50320	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05060	12753 UNIVERSITY AVE	CLIVE	IA	50325	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06677	4900 MILLS CIVIC PARKWAY	WEST DES MOINES	IA	50265	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05777	2930 E. UNIVERSITY AVE.	DES MOINES	IA	50317	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07453	104 E EUCLID AVE	DES MOINES	IA	50313-4507	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07967	15601 HICKMAN RD	CLIVE	IA	50325	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07996	2702 SE DELAWARE AVE	ANKENY	IA	50021	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09791	101 8TH ST SE	ALTOONA	IA	50009-1938	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07454	901 N ANKENY BLVD	ANKENY	IA	50023-4002	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16528	1704 INGERSOLL AVE STE 102	DES MOINES	IA	50309	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00359	2545 E EUCLID AVE	DES MOINES	IA	50317	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07968	6200 SE 14TH STREET	DES MOINES	IA	50320	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07833	3501 INGERSOLL AVE	DES MOINES	IA	50312-3406	01/17/2018	04/01/2018		01/17/2018
Contract Detail	Walgreens Central Fill #21394	2601 Hughes Road	Suite 103	Liberty	MO	64068	01/04/2024	04/01/2024		04/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	01/17/2018	04/01/2018	11/30/2021	12/01/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/17/2018	04/01/2018		01/17/2018
Contract Detail	WRIGHT PHARMACY	GRX HOLDINGS, LLC	303 SW 7TH STREET SUITE A	STUART	IA	50250-0159	01/17/2023	04/01/2023		04/01/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH160083A	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CENTER	1755 59th Place	WEST DES MOINES	IA	Terminated
DSH160083AA	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	Mercy North Surgery Clinic	800 E. First Street	Ankeny	IA	Terminated
DSH160083AB	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne Ankeny Endoscopy	800 E 1st St	Ankeny	IA	Active
DSH160083AC	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (4th Floor ICU)	1755 59th Place	West Des Moines	IA	Active
DSH160083AD	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (5th Floor Med/Surg)	1755 59th Place	West Des Moines	IA	Active
DSH160083AE	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (4th Floor Med/Surg)	1755 59th Place	West Des Moines	IA	Active
DSH160083AF	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES INTERNAL MED - Internal Medicine	411 LAUREL ST	DES MOINES	IA	Terminated
DSH160083AG	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES DIABETES AND EN - Diabetes and Endocrinology Care	411 LAUREL ST SUITE 3262	DES MOINES	IA	Active
DSH160083AH	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES NEUROPSYCHOLOGY - Neuropsychology	1111 6TH AVE EAST TOWER STE B1	DES MOINES	IA	Active
DSH160083AJ	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES NEUROSURGERY - Neurosurgery	1111 6TH AVE EAST TOWER STE B1	DES MOINES	IA	Active
DSH160083AK	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES SURGICAL GROUP - Surgical Group	411 LAUREL ST SUITE 2100	DES MOINES	IA	Active
DSH160083AL	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES PULMONARY INFEC - Pulmonary and Infectious Disease Care	411 LAUREL ST	DES MOINES	IA	Active
DSH160083AM	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH IOWA CORP - Iowa Heart Center (IH Heart Failure-Laurel)	411 LAUREL ST STE 1225	DES MOINES	IA	Active
DSH160083AN	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - Iowa Heart Center (IH Heart Failure-West University)	5880 UNIVERSITY AVE SUITE 102	WEST DES MOINES	IA	Active
DSH160083AP	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne Iowa Heart Center Des Moines (IH-SV Surg-Laurel) - Iowa Heart Center (IH-SV Surg-Laurel)	411 Laurel St STE A250	Des Moines	IA	Active
DSH160083AQ	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - Iowa Heart Center (IH-Arry Srvcs-West Univeristy)	5880 UNIVERSITY AVE SUITE 112	WEST DES MOINES	IA	Active
DSH160083AR	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH IOWA CORP - Iowa Heart Center (IH-Cardiac Rehab-Laurel)	411 LAUREL ST STE A250	DES MOINES	IA	Active
DSH160083AS	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - Iowa Heart Center (IH-Clinic Srvs-West University)	5880 UNIVERSITY AVE SUITE 102	WEST DES MOINES	IA	Active
DSH160083AT	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH IOWA CORP - Iowa Heart Center (IH-IV Structural-Laurel)	411 LAUREL ST STE A250	DES MOINES	IA	Active
DSH160083AU	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH IOWA CORP - Iowa Heart Center (IH-Clinic Srvs-Laurel)	411 LAUREL ST STE A250	DES MOINES	IA	Active
DSH160083AV	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - Iowa Heart Center (IH-PV Surg-West University)	5880 UNIVERSITY AVE SUITE 103	WEST DES MOINES	IA	Active
DSH160083AW	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH IOWA CORP - Iowa Heart Center (IH-Arry Srvcs-Laurel)	411 LAUREL ST STE A250	DES MOINES	IA	Active
DSH160083AX	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - Iowa Heart Center (IH-Vein Ctr-West University)	5880 UNIVERSITY AVE SUITE 103	WEST DES MOINES	IA	Active
DSH160083AY	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CE - MWL Radiology-Diagnostic	1755 59TH PL	WEST DES MOINES	IA	Active
DSH160083AZ	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CE - MWL Cardiac Rehab	1755 59TH PL	WEST DES MOINES	IA	Active
DSH160083BA	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CE - MWL Bariatric Program	1755 59TH PL	WEST DES MOINES	IA	Active
DSH160083BB	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CE - MercyOne West Des Moines Birthing Center	1755 59TH PL	WEST DES MOINES	IA	Active
DSH160083BC	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CE - MercyOne West Des Moines Labor and Birthing Center	1755 59TH PL	WEST DES MOINES	IA	Active
DSH160083BD	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - IH-Prevention and Wellness Clinic	5880 UNIVERSITY AVE SUITE 102	WEST DES MOINES	IA	Active
DSH160083BE	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	Mercyone Des Moines Cancer & Infusion Care - Newton - Infusion Center	204 N 4th Ave E	Newton	IA	Active
DSH160083C	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne Des Moines Cancer Care	411 LAUREL ST	DES MOINES	IA	Active
DSH160083D	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne Des Moines Ambulatory Surgery	411 LAUREL ST	DES MOINES	IA	Active
DSH160083E	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE CLIVE SLEEP CENTER	1449 NW 128th ST	CLIVE	IA	Active
DSH160083G	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES FIRST STEP RECOVERY	1750 48TH ST	DES MOINES	IA	Terminated
DSH160083H	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCY WEST RADIOLOGY	1601 NW 114TH ST	CLIVE	IA	Terminated
DSH160083J	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES CARDIAC & PULMONARY PREVENTION AND REHABILITATION	411 Laurel St	DES MOINES	IA	Active
DSH160083L	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne Des Moines Outpatient Cardiac Testing	411 Laurel St	DES MOINES	IA	Active
DSH160083M	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Outpatient Cardiac Testing	5880 UNIVERSITY AVE	WEST DES MOINES	IA	Active
DSH160083Q	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCY RADIOLOGY CENTER	12495 UNIVERSITY AVE	CLIVE	IA	Terminated
DSH160083R	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE RIVERSIDE REHABILITATION	501 SW 7th St.	DES MOINES	IA	Active
DSH160083T	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCY ATRIUM IMAGING SUITE	411 LAUREL ST.	DES MOINES	IA	Terminated
DSH160083U	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE CLIVE ENDOSCOPY	1601 NW 114TH ST	CLIVE	IA	Active
DSH160083V	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (Emergency Room)	1755 59th Place	West Des Moines	IA	Active
DSH160083W	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (Cath Lab)	1755 59th Place	West Des Moines	IA	Active
DSH160083X	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (3rd Floor Med Surg)	1755 59th Place	West Des Moines	IA	Active
DSH160083Y	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (Surgery)	1755 59th Place	West Des Moines	IA	Active
DSH160083Z	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (Recovery Room-PACU)	1755 59th Place	West Des Moines	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/26/2023 1:27:57 PM	9/4/2024 6:46:06 AM	9/4/2024 6:46 AM
Addresses	Shipping Address	Insert	Change Request		MercyOne Clive Pharmacy 1601 Northwest 114th Street Suite 234 Clive, IA 50325	6/12/2024 6:58 AM
Addresses	Shipping Address	Insert	Change Request		Mercyone Ankeny Pharmacy 800 East 1st Street Suite 1800 Ankeny, IA 50021	6/12/2024 6:58 AM
Contacts	Primary Contact	Update	Change Request	McVey, Kevin Patrick Interim Director of Pharmacy Catholic Health Initiatives 5156432934	Egbert, Jennifer Lynn Market Director of Pharmacy MercyOne 3047305888	2/5/2024 12:13 PM
Contacts	Authorizing Official	Update	AO Change Request	Roettger, Jodie Lynn Interim Chief Financial Officer MercyOne 5153589267	Donovan, Terri Jane Interim Chief Financial Officer MercyOne 5156438212	2/5/2024 7:34 AM
Details	Last Recertification Date	Update	Recertification	8/26/2022 11:24:40 AM	8/26/2023 1:27:57 PM	8/26/2023 1:27 PM
Contacts	Primary Contact	Update	Group Change Request	McVey, Kevin interim PIC Catholic Health Initiatives, Iowa Corp 5156432934	McVey, Kevin Patrick Interim Director of Pharmacy Catholic Health Initiatives 5156432934	8/9/2023 12:47 PM
Contacts	Authorizing Official	Update	Change Request	Rubin, Randall Senior Vice President Chief Financial Officer Catholic Health Initiatives, Iowa Corp. 5156432860	Roettger, Jodie Lynn Interim Chief Financial Officer MercyOne 5153589267	6/22/2023 1:09 PM
Details	Last Recertification Date	Update	Recertification	8/27/2021 9:41:38 AM	8/26/2022 11:24:40 AM	8/26/2022 11:24 AM
Contacts	Primary Contact	Update	Change Request	Jordan, Candace Marie Mkt Director of Pharmacy Catholic Health Initiatives, Iowa Corp 5152473262	McVey, Kevin interim PIC Catholic Health Initiatives, Iowa Corp 5156432934	6/3/2022 7:43 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/8/2022 2:53 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008106040	4/8/2022 2:53 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	4/8/2022 2:53 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	4/8/2022 2:53 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	4/8/2022 2:53 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	4/8/2022 2:53 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	4/8/2022 2:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		29927	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		114284105	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000159864	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		420680448001	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10026115701	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300034708	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		07580863	1/13/2022 2:43 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	1/13/2022 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	1/13/2022 2:43 PM
Details	Last Recertification Date	Update	Recertification	9/9/2020 7:19:11 AM	8/27/2021 9:41:38 AM	8/27/2021 9:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/18/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		011266400	1/18/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	1/18/2021 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/18/2021 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	1/18/2021 2:46 PM
Addresses	Shipping Address	Delete	Change Request	MercyOne Ankeny Pharmacy 800 East 1st Street Suite 1800 Ankeny, IA 50021-2100		1/12/2021 11:26 AM
Addresses	Shipping Address	Delete	Change Request	MercyOne Clive Pharmacy 1601 NW 114th Street Suite 234 Clive, IA 50325-7007		1/12/2021 11:26 AM
Addresses	Shipping Address	Delete	Change Request	MercyOne Des Moines Medical Center Pharmacy 1111 Sixth Avenue Des Moines, IA 50314-2611		1/12/2021 11:26 AM
Addresses	Shipping Address	Delete	Change Request	MercyOne Des Moines Pharmacy 1111 Sixth Avenue Des Moines, IA 50314-2610		1/12/2021 11:26 AM
Addresses	Main Address	Update	Change Request	1111 SIXTH AVE DES MOINES, IA 50314-2610	1111 6th Avenue DES MOINES, IA 50314-2610	1/12/2021 11:26 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1508964883 ( )		9/9/2020 7:19 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1538395975 ( )		9/9/2020 7:19 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508964883	9/9/2020 7:19 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/9/2020 7:19 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1538395975	9/9/2020 7:19 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/9/2020 7:19 AM
Details	Last Recertification Date	Update	Recertification	9/3/2019 9:19:14 AM	9/9/2020 7:19:11 AM	9/9/2020 7:19 AM
Contacts	Primary Contact	Update	Recertification	Jordan, Candace Mkt Director of Pharmacy Catholic Health Initiatives, Iowa Corp 5152473262	Jordan, Candace Marie Mkt Director of Pharmacy Catholic Health Initiatives, Iowa Corp 5152473262	9/8/2020 4:41 PM
Details	Entity Subname	Update	OPA Edit	MERCY MEDICAL CENTER	MERCYONE DES MOINES MEDICAL CENTER	7/17/2020 8:37 AM
Contacts	Primary Contact	Update	Change Request	Young, Gregory A. DIRECTOR OF PHARMACY Catholice Health Initiatives, Iowa Corp. 5152473262	Jordan, Candace Mkt Director of Pharmacy Catholic Health Initiatives, Iowa Corp 5152473262	7/8/2020 7:00 AM
Details	Last Recertification Date	Update	Recertification	8/24/2018 10:14:55 AM	9/3/2019 9:19:14 AM	9/3/2019 9:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2019 4:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0600833	6/12/2019 4:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	6/12/2019 4:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2019 4:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0600002	6/12/2019 4:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	6/12/2019 4:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	6/12/2019 4:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	6/12/2019 4:08 PM
Addresses	Shipping Address	Delete	Change Request	Mercy West Pharmacy 1601 NW 114th Street Suite 234 Clive, IA 50325-7007		6/4/2019 10:41 AM
Addresses	Shipping Address	Delete	Change Request	Mercy Outpatient Pharmacy 1111 Sixth Avenue Des Moines, IA 50314-2610		6/4/2019 10:41 AM
Addresses	Shipping Address	Delete	Change Request	Mercy North Pharmacy 800 East 1st Street Suite 1800 Ankeny, IA 50021-2100		6/4/2019 10:41 AM
Addresses	Shipping Address	Delete	Change Request	Mercy Medical Center Pharmacy 1111 Sixth Avenue Des Moines, IA 50314-2611		6/4/2019 10:41 AM
Addresses	Shipping Address	Insert	Change Request		MercyOne Des Moines Pharmacy 1111 Sixth Avenue Des Moines, IA 50314-2610	6/4/2019 10:41 AM
Addresses	Shipping Address	Insert	Change Request		MercyOne Ankeny Pharmacy 800 East 1st Street Suite 1800 Ankeny, IA 50021-2100	6/4/2019 10:41 AM
Addresses	Shipping Address	Insert	Change Request		MercyOne Clive Pharmacy 1601 NW 114th Street Suite 234 Clive, IA 50325-7007	6/4/2019 10:41 AM
Addresses	Shipping Address	Insert	Change Request		MercyOne Des Moines Medical Center Pharmacy 1111 Sixth Avenue Des Moines, IA 50314-2611	6/4/2019 10:41 AM
Details	Last Recertification Date	Update	Recertification	11/9/2017 1:54:47 PM	8/24/2018 10:14:55 AM	8/24/2018 10:14 AM
Contacts	Authorizing Official	Update	Change Request	Wegner, Michael A. SENIOR VP-CFO Mercy Medical Center 5152474291	Rubin, Randall Senior Vice President Chief Financial Officer Catholic Health Initiatives, Iowa Corp. 5156432860	3/1/2018 9:37 AM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/9/2017 1:54:47 PM	11/9/2017 1:54 PM
Contacts	Authorizing Official	Update		Wegner, Michael A. SENIOR VP-CFO 5152474291	Wegner, Michael A. SENIOR VP-CFO Mercy Medical Center 5152474291	10/2/2017 3:26 PM
Contacts	Primary Contact	Update		Young, Gregory A. DIRECTOR OF PHARMACY 5152473262	Young, Gregory A. DIRECTOR OF PHARMACY Catholice Health Initiatives, Iowa Corp. 5152473262	10/2/2017 1:05 PM
Contacts	Authorizing Official	Insert			Wegner, Michael A. SENIOR VP-CFO 5152474291	7/20/2017 9:17 AM
Addresses	Main Address	Insert			1111 SIXTH AVE DES MOINES, IA 50314-2610	6/30/2017 11:02 AM
Addresses	Shipping Address	Insert			Mercy West Pharmacy 1601 NW 114th Street Suite 234 Clive, IA 50325-7007	6/30/2017 11:02 AM
Addresses	Shipping Address	Insert			Mercy Outpatient Pharmacy 1111 Sixth Avenue Des Moines, IA 50314-2610	6/30/2017 11:02 AM
Addresses	Shipping Address	Insert			Mercy North Pharmacy 800 East 1st Street Suite 1800 Ankeny, IA 50021-2100	6/30/2017 11:02 AM
Addresses	Shipping Address	Insert			Mercy Medical Center Pharmacy 1111 Sixth Avenue Des Moines, IA 50314-2611	6/30/2017 11:02 AM
Contacts	Primary Contact	Insert			Young, Gregory A. DIRECTOR OF PHARMACY 5152473262	6/30/2017 11:02 AM
Details	Last Recertification Date	Update		8/13/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 3:27 PM
Details	Last Recertification Date	Update		9/3/2014 12:00:00 AM	8/13/2015 12:00:00 AM	8/13/2015 1:56 PM
Details	Last Recertification Date	Update		9/11/2013 12:00:00 AM	9/3/2014 12:00:00 AM	9/3/2014 12:42 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/11/2013 12:00:00 AM	9/11/2013 8:53 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/29/2012 12:11 PM
Details	Last Recertification Date	Insert				3/15/2011 10:23 AM
Details	Grant Number	Insert				3/15/2011 10:23 AM
Details	340B ID	Insert			DSH160083	3/15/2011 10:23 AM
Details	Is Authorizing Official EHB Data	Insert				3/15/2011 10:23 AM
Dates	Last Date That 340B Drugs Purchased	Insert				3/15/2011 10:23 AM
Details	Medicare Provider Number	Insert			160083	3/15/2011 10:23 AM
Details	Entity Name	Insert			CATHOLIC HEALTH INITIATIVES - IOWA, CORP	3/15/2011 10:23 AM
Details	Program Code	Insert			DSH	3/15/2011 10:23 AM
Details	Entity Subname	Insert			MERCY MEDICAL CENTER	3/15/2011 10:23 AM
Dates	Participating Approval Date	Insert			3/15/2011 12:00:00 AM	3/15/2011 10:23 AM
Details	State	Insert			Active	3/15/2011 10:23 AM
Dates	Registration Date	Insert			3/3/2011 12:00:00 AM	3/15/2011 10:23 AM
Dates	Signed By Date	Insert			2/23/2011 12:00:00 AM	3/15/2011 10:23 AM
Dates	Start Date	Insert			4/1/2011 12:00:00 AM	3/15/2011 10:23 AM
Terminations	Termination Comments	Insert				3/15/2011 10:23 AM
Terminations	Termination Date	Insert				3/15/2011 10:23 AM
Terminations	Termination Effective Date	Insert				3/15/2011 10:23 AM
Terminations	Termination Reason	Insert				3/15/2011 10:23 AM