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EVANS CROSSING PHARMACY
DSH160067 MercyOne Waterloo Medical Center
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Covered Entity Details
Entity Name
MercyOne Waterloo Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160067
Entity Address
3421 W 9TH STREET
WATERLOO, IA 50702
Medicare Provider Number
160067
Participating Start Date
1/1/2011
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
EVANS CROSSING PHARMACY
Pharmacy Address
BLACKHAWK PHARMACY
3506 LAFAYETTE RD
EVANSDALE, IA 50707-1025
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Timothy Huber, Vice President of Finance
(319) 272-7607
Contract Pharmacy Representative
Greenwood Pharmacy
Robert Greenwood, President
(319) 236-8067
Signed By Date
7/17/2018
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