Contract Pharmacy Details

IOWA CVS PHARMACY, L.L.C.
CAH141319-01 Henry District Hospital

Covered Entity Details

Entity Name

Henry District Hospital

Subdivision Name

Hammond Henry Hospital Medical Group -Kewanee - Family Practice

Type

Critical Access Hospital

340B ID

CAH141319-01

Entity Address

1258 W. South Street
Suite 2
Kewanee, IL 61443-8300

Medicare Provider Number

141319

Outpatient Facility Provider Number

148576

Participating Start Date

1/1/2018

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

IOWA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 08659
1777 DIVISION ST.
DAVENPORT, IA 52804

Pharmacy Comments

Contract Details

Approval Date

7/7/2021

Contract Begin Date

10/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/9/2021
Agreement registered in error

Contacts

Covered Entity Signing Official

Laura J Domino, Vice President of Patient Care Services
(309) 944-9101

Contract Pharmacy Representative

Hammond-Henry Hospital
Laura J Domino, Vice President of Patient Care Services
(309) 944-9101

Signed By Date

7/7/2021

340B Drug Pricing Program Database