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WAL-MART PHARMACY 10-2764
DSH160083 CATHOLIC HEALTH INITIATIVES - IOWA, CORP
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Covered Entity Details
Entity Name
CATHOLIC HEALTH INITIATIVES - IOWA, CORP
Subdivision Name
MERCYONE DES MOINES MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH160083
Entity Address
1111 6th Avenue
DES MOINES, IA 50314-2610
Medicare Provider Number
160083
Participating Start Date
4/1/2011
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2764
Pharmacy Address
3501 8TH STREET SW
ALTOONA, IA 50009
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Randall Rubin, Senior Vice President Chief Financial Officer
(515) 643-2860
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/12/2019
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