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CHI HEALTH SPECIALTY PHARMACY
DSH160064 MercyOne North Iowa Medical Center
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Covered Entity Details
Entity Name
MercyOne North Iowa Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160064
Entity Address
1000 4TH STREET SW
MASON CITY, IA 50401
Medicare Provider Number
160064
Participating Start Date
10/1/2019
Last Recertification Date
8/19/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
CHI HEALTH SPECIALTY PHARMACY
Pharmacy Address
7710 MERCY RD STE 102
OMAHA, NE 68124-2339
Pharmacy Comments
Contract Details
Approval Date
7/26/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
DANETTE ZOOK, RHM VP Finance
(641) 428-7989
Contract Pharmacy Representative
Alegent Creighton Health
Michael Tiesi, Regional Senior Director of Pharmacy Services
(402) 717-2614
Signed By Date
7/12/2019
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