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WAGNER PHARMACY 1 CO
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
WAGNER PHARMACY 1 CO
Pharmacy Address
1726 N 2ND ST
CLINTON, IA 52732
Pharmacy Comments
Contract Details
Approval Date
6/29/2020
Contract Begin Date
6/29/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/29/2021
Ownership change
Contacts
Covered Entity Signing Official
Amy E Berentes, EVP/Chief Operating Officer
(563) 244-5608
Contract Pharmacy Representative
Wagner Pharmacy Co
Timothy A Wright, President & CEO
(563) 242-0626
Signed By Date
6/29/2020
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