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HY-VEE PHARMACY (1075)
DSH160080 MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center
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Covered Entity Details
Entity Name
MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160080
Entity Address
1410 N FOURTH STREET
CLINTON, IA 52732
Medicare Provider Number
160080
Participating Start Date
4/1/2020
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY (1075)
Pharmacy Address
901 SOUTH 4TH ST
CLINTON, IA 52732
Pharmacy Comments
Contract Details
Approval Date
2/3/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/4/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Amy E Berentes, EVP/Chief Operating Officer
(563) 244-5608
Contract Pharmacy Representative
Hy-vee Inc.
Marshall Sanders, 340B Program Manager
(515) 267-6009
Signed By Date
1/15/2020
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