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HY-VEE PHARMACY FULFILLMENT CENTER 4016
CAH161363-00 Montgomery County Memorial Hospital
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Covered Entity Details
Entity Name
Montgomery County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161363-00
Entity Address
2301 Eastern Avenue
Red Oak, IA 51566
Medicare Provider Number
161363
Participating Start Date
4/1/2012
Last Recertification Date
8/13/2024
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
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rick J. Leinen, Chief Financial Officer
(712) 623-7150
Contract Pharmacy Representative
Hy-vee Inc.
Marshall Sanders, 340B Program Manager
(515) 267-6009
Signed By Date
7/12/2019
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