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LAGRANGE PHARMACY URBANA
CAH161349-00 Virginia Gay Hospital
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Covered Entity Details
Entity Name
Virginia Gay Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161349-00
Entity Address
502 N 9th Ave
Vinton, IA 52349
Medicare Provider Number
161349
Participating Start Date
4/1/2012
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
LAGRANGE PHARMACY URBANA
Pharmacy Address
LAGRANGE PHARMACY URBANA
1002 W MAIN ST
URBANA, IA 52345
Pharmacy Comments
Contract Details
Approval Date
1/10/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kelly Jean Henkle, Director of General Services
(319) 472-6379
Contract Pharmacy Representative
LaGrange Pharmacy Urbana
Dan LaGrange, President
(319) 443-6337
Signed By Date
1/10/2020
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