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KMART PHARMACY #7767
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
KMART PHARMACY #7767
Pharmacy Address
1405 S GRAND AVE
CHARLES CITY, IA 50616-3670
Pharmacy Comments
Contract Details
Approval Date
10/17/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
DANETTE ZOOK, RHM VP Finance
(641) 428-7989
Contract Pharmacy Representative
BI-LO
Jennifer Spears, Director Administration/Compliance
(904) 783-5183
Signed By Date
10/17/2019
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