340B Drug Pricing Program Database
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DSH160067CL MercyOne Waterloo Medical Center (Active)
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Main Details
Name
MercyOne Waterloo Medical Center
Subdivision Name
MercyOne Independence Family Medicine
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH160067CL
Medicare Provider Number
160067
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/7/2019
Participating Start Date
4/1/2019
Participating Approval Date
2/8/2019
Last Recertification Date
9/5/2024
Contacts
Authorizing Official
MercyOne NorthEast Iowa
Timothy Huber, Vice President of Finance
(319) 272-7607
Primary Contact
Covenant Medical Center
Jaclyn Annette Van Raden, 340B Contract Pharmacy Analyst
(319) 272-8636
Addresses
Street Address
2004 ENTERPRISE CT
INDEPENDENCE, IA 50644-9611
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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