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BUENA VISTA REGIONAL MEDICAL CENTER PHAR
SCH160016-00 TRINITY REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
TRINITY REGIONAL MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH160016-00
Entity Address
802 KENYON ROAD
FORT DODGE, IA 50501
Medicare Provider Number
160016
Participating Start Date
10/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
BUENA VISTA REGIONAL MEDICAL CENTER PHAR
Pharmacy Address
620 NORTHWESTERN DR
POD 2
STORM LAKE, IA 50588
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Troy Allan Martens, COO
(515) 574-8585
Contract Pharmacy Representative
Buena Vista Regional Medical Center
JON David MCKENNA, DIRECTOR OF PHARMACY
(712) 213-8695
Signed By Date
1/15/2020
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