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LARRY'S PHARMACY
SCH160016-00 TRINITY REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
TRINITY REGIONAL MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH160016-00
Entity Address
802 KENYON ROAD
FORT DODGE, IA 50501
Medicare Provider Number
160016
Participating Start Date
10/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
LARRY'S PHARMACY
Pharmacy Address
1310 10TH AVE. N.
HUMBOLDT, IA 50548
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
Troy Allan Martens, COO
(515) 574-8585
Contract Pharmacy Representative
Larry's Pharmacy
Carleen Milewski, Owner
(515) 332-1627
Signed By Date
7/12/2019
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