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WALGREEN CO.
RRC160057-00 Southeast Iowa Regional Medical Center
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Covered Entity Details
Entity Name
Southeast Iowa Regional Medical Center
Subdivision Name
Type
Rural Referral Center
340B ID
RRC160057-00
Entity Address
1221 S. GEAR
WEST BURLINGTON, IA 52655
Medicare Provider Number
160057
Participating Start Date
1/1/2011
Last Recertification Date
9/10/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #11759
2639 AVENUE L
FORT MADISON, IA 52627-3840
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
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jeremy Alexander, CFO
(319) 768-3280
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/3/2020
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