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HY-VEE PHARMACY FULFILLMENT CENTER 4016
CAH161300-00 BAUM HARMON MERCY HOSPITAL DBA MERCYONE PRIMGHAR MEDICAL CENTER
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Covered Entity Details
Entity Name
BAUM HARMON MERCY HOSPITAL DBA MERCYONE PRIMGHAR MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161300-00
Entity Address
255 NORTH WELCH AVENUE
PRIMGHAR, IA 51245
Medicare Provider Number
161300
Participating Start Date
1/1/2011
Last Recertification Date
9/4/2024
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY FULFILLMENT CENTER 4016
Pharmacy Address
HY-VEE INC
4707 FLUER DR
DES MOINES, IA 50321
Pharmacy Comments
11-22-2013 Address correction
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
SUE E MCCAULEY, CAH FINANCE MANAGER-BHMH OMH
(712) 957-2300 Ext: 2303
Contract Pharmacy Representative
Hy-vee Inc.
Marshall Sanders, 340B Program Manager
(515) 267-6009
Signed By Date
1/15/2020
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