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MANITO PHARMACY
CAH141313-00 MASON DISTRICT HOSPITAL
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Covered Entity Details
Entity Name
MASON DISTRICT HOSPITAL
Subdivision Name
MASON DISTRICT HOSPITAL
Type
Critical Access Hospital
340B ID
CAH141313-00
Entity Address
615 NORTH PROMENADE STREET
HAVANA, IL 62644-0530
Medicare Provider Number
141313
Participating Start Date
7/1/2020
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
MANITO PHARMACY
Pharmacy Address
R & Q CORPORATION
406 S ADAMS ST
MANITO, IL 61546-9315
Pharmacy Comments
Contract Details
Approval Date
4/21/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Leann Kay Bonnett, CFO
(309) 543-8505
Contract Pharmacy Representative
Wolter's Drug Store
Don Quinones, Owner
(309) 543-2253 Ext: 2444
Signed By Date
4/16/2020
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