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LAGRANGE PHARMACY INC
CAH161306-00 ST. LUKE'S JONES REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. LUKE'S JONES REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161306-00
Entity Address
1795 HIGHWAY 64 EAST
ANAMOSA, IA 52205
Medicare Provider Number
161306
Participating Start Date
1/1/2011
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
LAGRANGE PHARMACY INC
Pharmacy Address
LAGRANGE PHARMACY
111 W 4TH ST
VINTON, IA 52349
Pharmacy Comments
Contract Details
Approval Date
4/11/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ERIC BRIESEMEISTER, CEO
(319) 481-6301
Contract Pharmacy Representative
La Grange Pharmacy
Dan Lagrange, Owner
(319) 472-4274
Signed By Date
4/11/2019
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