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EVANS CROSSING PHARMACY
DSH160110 Allen Memorial Hospital Corporation
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Covered Entity Details
Entity Name
Allen Memorial Hospital Corporation
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160110
Entity Address
1825 Logan Avenue
Waterloo, IA 50703-1916
Medicare Provider Number
160110
Participating Start Date
1/1/2014
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
EVANS CROSSING PHARMACY
Pharmacy Address
BLACKHAWK PHARMACY
3506 LAFAYETTE RD
EVANSDALE, IA 50707-1025
Pharmacy Comments
Contract Details
Approval Date
1/13/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Pamela K. Delagardelle, President/CEO
(319) 235-3606
Contract Pharmacy Representative
Greenwood Pharmacy
Robert Greenwood, President
(319) 236-8067
Signed By Date
1/13/2022
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