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IOWA CVS PHARMACY, L.L.C.
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
IOWA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08544
1825 E SAN MARNAN DRIVE
WATERLOO, IA 50702
Pharmacy Comments
Contract Details
Approval Date
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
DANETTE ZOOK, RHM VP Finance
(641) 428-7989
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/14/2020
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