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HERITAGE PARK PHARMACY
DSH160057Q Southeast Iowa Regional Medical Center
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Covered Entity Details
Entity Name
Southeast Iowa Regional Medical Center
Subdivision Name
EMERGENCY DEPARTMENT - SOUTHEAST IOWA REGIONAL MEDICAL CENTER - Emergency Department
Type
Disproportionate Share Hospital
340B ID
DSH160057Q
Entity Address
5445 Avenue O
Fort Madison, IA 52627
Medicare Provider Number
160057
Outpatient Facility Provider Number
Participating Start Date
4/1/2022
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
HERITAGE PARK PHARMACY
Pharmacy Address
1223 S GEAR AVE STE 105
WEST BURLINGTON, IA 52655-1690
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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