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CHI HEALTH PHARMACY WEST BROADWAY
DSH280081 CHI Health Immanuel
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Covered Entity Details
Entity Name
CHI Health Immanuel
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH280081
Entity Address
6901 N. 72ND ST
OMAHA, NE 68122
Medicare Provider Number
280081
Participating Start Date
4/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
CHI HEALTH PHARMACY WEST BROADWAY
Pharmacy Address
3135 W BROADWAY
SUITE 101
COUNCIL BLUFFS, IA 51501
Pharmacy Comments
Contract Details
Approval Date
10/11/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/11/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
TIM SCHNACK, CFO
(402) 572-3701
Contract Pharmacy Representative
CHI Health
Gregory Schardt, Division Director of Pharmacy Operations
(402) 206-3370
Signed By Date
10/11/2019
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