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SCOTT PHARMACY
CAH161312-01 GUTTENBERG MUNICIPAL HOSPITAL
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Covered Entity Details
Entity Name
GUTTENBERG MUNICIPAL HOSPITAL
Subdivision Name
Cornerstone Family Practice
Type
Critical Access Hospital
340B ID
CAH161312-01
Entity Address
200 MAIN ST
CORNERSTONE FAMILY PRACTICE
GUTTENBERG, IA 52052-9108
Medicare Provider Number
161312
Outpatient Facility Provider Number
168552
Participating Start Date
1/1/2019
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
SCOTT PHARMACY
Pharmacy Address
238 S MAIN ST
PO BOX 188
FAYETTE, IA 52142
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/12/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lisa Manson, Director of Ambulatory Services
(563) 252-1121
Contract Pharmacy Representative
Scott Pharmacy
David J Scott, PharmD, MBA
(563) 425-4530
Signed By Date
1/15/2019
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