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HY-VEE PHARMACY FULFILLMENT CENTER 4016
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
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
7/26/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/22/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DANETTE ZOOK, RHM VP Finance
(641) 428-7989
Contract Pharmacy Representative
Hy-vee Inc.
Marshall Sanders, 340B Program Manager
(515) 267-6009
Signed By Date
7/12/2019
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