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PROCARE PHARMACY, L.L.C.
RRC160153-00 MercyOne Siouxland Medical Center
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Covered Entity Details
Entity Name
MercyOne Siouxland Medical Center
Subdivision Name
Type
Rural Referral Center
340B ID
RRC160153-00
Entity Address
801 FIFTH STREET
SIOUX CITY, IA 51101
Medicare Provider Number
160153
Participating Start Date
10/1/2018
Last Recertification Date
9/4/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203
Pharmacy Comments
Contract Details
Approval Date
10/15/2021
Contract Begin Date
11/3/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Beth Hughes, President
(712) 279-2018
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/15/2021
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