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HERITAGE PARK PHARMACY
DSH160122 Fort Madison Community Hospital
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Covered Entity Details
Entity Name
Fort Madison Community Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160122
Entity Address
5445 Avenue O
Fort Madison, IA 52627
Medicare Provider Number
160122
Participating Start Date
7/1/2014
Last Recertification Date
8/17/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
HERITAGE PARK PHARMACY
Pharmacy Address
1223 S GEAR AVE STE 105
WEST BURLINGTON, IA 52655-1690
Pharmacy Comments
Contract Details
Approval Date
1/9/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jeremy Alexander, CFO
(319) 376-2125
Contract Pharmacy Representative
Great River Health System
Brian J. Anderson, Director of Pharmacies
(319) 768-3950
Signed By Date
1/9/2019
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