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MASON CITY 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
MASON CITY PHARMACY
Pharmacy Address
149 E CHESTNUT ST
MASON CITY, IL 62664-1403
Pharmacy Comments
Contract Details
Approval Date
4/8/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Leann Kay Bonnett, CFO
(309) 543-8505
Contract Pharmacy Representative
Mason City Pharmacy
Julianne Manuel, Owner
(217) 482-5985
Signed By Date
4/8/2021
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