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WAL-MART PHARMACY 10-5031
DSH160080 MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center
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Covered Entity Details
Entity Name
MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160080
Entity Address
1410 N FOURTH STREET
CLINTON, IA 52732
Medicare Provider Number
160080
Participating Start Date
4/1/2020
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5031
Pharmacy Address
8280 NORTH CORTARO
TUCSON, AZ 85743
Pharmacy Comments
Contract Details
Approval Date
10/19/2021
Contract Begin Date
10/27/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/3/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Amy E Berentes, EVP/Chief Operating Officer
(563) 244-5608
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/19/2021
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