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HY-VEE PHARMACY (#1051)
SCH160005-00 ST. ANTHONY REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
ST. ANTHONY REGIONAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH160005-00
Entity Address
311 SOUTH CLARK STREET
CARROLL, IA 51401
Medicare Provider Number
160005
Participating Start Date
10/1/2017
Last Recertification Date
9/12/2023
Entity Termination Date
5/22/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY (#1051)
Pharmacy Address
905 US HWY 30 WEST
CARROLL, IA 51401
Pharmacy Comments
Contract Details
Approval Date
7/16/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/22/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John Munson, Vice President & CFO
(712) 794-5115
Contract Pharmacy Representative
Hy-Vee, Inc
Ashley Plum, 340B Coordinator
(515) 559-5708
Signed By Date
7/16/2018
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