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HY-VEE PHARMACY FULFILLMENT CENTER 4016
SCH160080-02 Mercy Medical Center
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Covered Entity Details
Entity Name
Mercy Medical Center
Subdivision Name
CLINTON / Renal Dialysis
Type
Sole Community Hospital
340B ID
SCH160080-02
Entity Address
638 S BLUFF BLVD
CLINTON, IA 52732-4742
Medicare Provider Number
160080
Outpatient Facility Provider Number
162313
Participating Start Date
1/1/2015
Last Recertification Date
8/29/2019
Entity Termination Date
4/1/2020
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
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Amy E Berentes, EVP/Chief Operating Officer
(563) 244-5608
Contract Pharmacy Representative
Hy-vee Inc.
Marshall Sanders, 340B Program Manager
(515) 267-6009
Signed By Date
10/15/2019
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