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WALGREEN CO.
SCH160080-00 Mercy Medical Center
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Covered Entity Details
Entity Name
Mercy Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH160080-00
Entity Address
1410 North 4th St
Clinton, IA 52732
Medicare Provider Number
160080
Participating Start Date
10/1/2014
Last Recertification Date
8/31/2019
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 05144
1905 N 2ND ST
CLINTON, IA 52732
Pharmacy Comments
Contract Details
Approval Date
1/10/2020
Contract Begin Date
4/1/2020
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/10/2020
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