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WAL-MART PHARMACY 10-2714
DSH160064 MercyOne North Iowa Medical Center
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Covered Entity Details
Entity Name
MercyOne North Iowa Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160064
Entity Address
1000 4TH STREET SW
MASON CITY, IA 50401
Medicare Provider Number
160064
Participating Start Date
10/1/2019
Last Recertification Date
8/19/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2714
Pharmacy Address
500 11TH STREET, S.W.
SPENCER, IA 51301
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
7/26/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/31/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diane Fischels, RHM COO
(641) 428-7362
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/15/2021
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