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HOLSTEIN COMMUNITY PHARMACY
CAH161362-00 SIOUX VALLEY MEMORIAL HOSPITAL ASSOCIATION D/B/A CHEROKEE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
SIOUX VALLEY MEMORIAL HOSPITAL ASSOCIATION D/B/A CHEROKEE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161362-00
Entity Address
300 SIOUX VALLEY DRIVE
CHEROKEE, IA 51012
Medicare Provider Number
161362
Participating Start Date
9/30/2010
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
HOLSTEIN COMMUNITY PHARMACY
Pharmacy Address
108 N MAIN ST
HOLSTEIN, IA 51025
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
6/20/2022
Ownership change
Contacts
Covered Entity Signing Official
Julie Fenoglio, Interim CEO and CNO
(712) 225-3368 Ext: 207
Contract Pharmacy Representative
CMSRx Inc.
Anthony Puffett, President
(712) 225-2320
Signed By Date
1/15/2019
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