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HY-VEE PHARMACY FULFILLMENT CENTER 4016
CAH161377-01 MercyOne Centerville Medical Center
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Covered Entity Details
Entity Name
MercyOne Centerville Medical Center
Subdivision Name
MERCY RURAL HEALTH CLINIC DBA MercyOne Centerville Medical Clinic
Type
Critical Access Hospital
340B ID
CAH161377-01
Entity Address
19942 ST. JOSEPH'S DRIVE
CENTERVILLE, IA 52544
Medicare Provider Number
161377
Outpatient Facility Provider Number
168533
Participating Start Date
7/1/2011
Last Recertification Date
8/12/2024
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
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ANN E YOUNG, INTERIM PRESIDENT
(641) 437-3434
Contract Pharmacy Representative
Hy-vee Inc.
Marshall Sanders, 340B Program Manager
(515) 267-6009
Signed By Date
7/15/2019
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