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AMBER ENTERPRISES, INC
DSH160033 GENESIS MEDICAL CENTER - DAVENPORT
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Covered Entity Details
Entity Name
GENESIS MEDICAL CENTER - DAVENPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160033
Entity Address
1227 EAST RUSHOLME
DAVENPORT, IA 52803
Medicare Provider Number
160033
Participating Start Date
1/1/2019
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
AMBER ENTERPRISES, INC
Pharmacy Address
DBA AMBER SPECIALTY PHARMACY
1 E ERIE ST STE 630
CHICAGO, IL 60611
Pharmacy Comments
Contract Details
Approval Date
1/3/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/7/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mark Rogers, CFO
(563) 421-6513
Contract Pharmacy Representative
Amber Enterprises
Kelley Miller, 340B Program Manager
(402) 861-7560
Signed By Date
1/3/2020
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