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HY-VEE PHARMACY FULFILLMENT CENTER 4016
RRC160057-00 Southeast Iowa Regional Medical Center
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Covered Entity Details
Entity Name
Southeast Iowa Regional Medical Center
Subdivision Name
Type
Rural Referral Center
340B ID
RRC160057-00
Entity Address
1221 S. GEAR
WEST BURLINGTON, IA 52655
Medicare Provider Number
160057
Participating Start Date
1/1/2011
Last Recertification Date
9/10/2021
Entity Termination Date
4/1/2022
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
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Matthew John Wenzel, President and CEO
(319) 768-3266
Contract Pharmacy Representative
Hy-vee Inc.
Marshall Sanders, 340B Program Manager
(515) 267-6009
Signed By Date
4/12/2019
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