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HY-VEE PHARMACY FULFILLMENT CENTER 4016
DSH240022 SANFORD WORTHINGTON MEDICAL CENTER
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Covered Entity Details
Entity Name
SANFORD WORTHINGTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240022
Entity Address
1018 6TH AVENUE
WORTHINGTON, MN 56187-0097
Medicare Provider Number
240022
Participating Start Date
1/1/2010
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY FULFILLMENT CENTER 4016
Pharmacy Address
HY-VEE INC
4707 FLUER DR
DES MOINES, IA 50321
Pharmacy Comments
11-22-2013 Address correction
Contract Details
Approval Date
10/11/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/14/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Thomas Cleveland, Director of Finance
(605) 312-9351
Contract Pharmacy Representative
Hy Vee
Kristin Williams, Senior VP, Pharmacy Operations
(515) 559-5780
Signed By Date
10/11/2018
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