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KMART PHARMACY #7767
SCH160064-00 MERCYONE NORTH IOWA MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCYONE NORTH IOWA MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH160064-00
Entity Address
1000 4TH STREET SW
MASON CITY, IA 50401
Medicare Provider Number
160064
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
KMART PHARMACY #7767
Pharmacy Address
1405 S. GRAND
CHARLES CITY, IA 50616
Pharmacy Comments
Contract Details
Approval Date
9/7/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/11/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
DANETTE ZOOK, RHM VP Finance
(641) 428-7989
Contract Pharmacy Representative
Sears
Jennifer Speares, Director of Administration and Compliance
(847) 286-5116
Signed By Date
9/7/2018
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