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WALGREEN CO.
DSH160082 IOWA METHODIST MEDICAL CENTER
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Covered Entity Details
Entity Name
IOWA METHODIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160082
Entity Address
1200 PLEASANT STREET
DES MOINES, IA 50309
Medicare Provider Number
160082
Participating Start Date
7/1/2017
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16528
1704 INGERSOLL AVE STE 102
DES MOINES, IA 50309
Pharmacy Comments
Contract Details
Approval Date
7/12/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eric Lothe, SVP/COO
(515) 241-5858
Contract Pharmacy Representative
Walgreens
Tony Joe Chriscoe, 340 Client Relations Analyst
(847) 315-5806
Signed By Date
7/12/2021
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