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SCH140167-00 IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME (Terminated)
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Main Details
Name
IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Subdivision Name
Type
Sole Community Hospital
Rural
Yes
340B ID
SCH140167-00
Medicare Provider Number
140167
Additional Details
Current Program Status
Terminated
Registration Date
1/15/2014
Participating Start Date
4/1/2014
Participating Approval Date
2/11/2014
Last Recertification Date
8/28/2019
Termination Date
Termination Reason
10/1/2020
Failure to recertify
Contacts
Authorizing Official
Iroquois Resident Home
Jeff Petersen, VP
(815) 432-7720
Primary Contact
IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
MICHAEL A SANDSMARK, PHARMACIST
(815) 432-7746
Addresses
Street Address
200 E FAIRMAN AVE
WATSEKA, IL 60970-1644
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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