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SHOPKO PHARMACY #2041
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
SHOPKO PHARMACY #2041
Pharmacy Address
1209 18TH AVENUE NORTHWEST
AUSTIN, MN 55912-1881
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
1/8/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
DANETTE ZOOK, RHM VP Finance
(641) 428-7989
Contract Pharmacy Representative
ShopKo
Lorie Neumann, Contracting & Compliance
(920) 429-4726
Signed By Date
9/7/2018
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