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CYSTIC FIBROSIS SERVICES, LLC
DSH160057S Southeast Iowa Regional Medical Center
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Covered Entity Details
Entity Name
Southeast Iowa Regional Medical Center
Subdivision Name
INTERNAL MEDICINE-SOUTHEAST IOWA RE - Internal Medicine
Type
Disproportionate Share Hospital
340B ID
DSH160057S
Entity Address
1223 S GEAR AVE
STE 108
WEST BURLINGTON, IA 52655-1685
Medicare Provider Number
160057
Outpatient Facility Provider Number
Participating Start Date
4/1/2022
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
2/16/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeremy Alexander, CFO
(319) 768-3280
Contract Pharmacy Representative
Southeast Iowa Regional Medical Center
Steve Frigo, Director, Pharmacy
(319) 768-3971
Signed By Date
2/16/2022
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