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WALGREEN CO.
DSH160057 Southeast Iowa Regional Medical Center
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Covered Entity Details
Entity Name
Southeast Iowa Regional Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160057
Entity Address
1221 SOUTH GEAR AVENUE
WEST BURLINGTON, IA 52655
Medicare Provider Number
160057
Participating Start Date
4/1/2022
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #11759
2639 AVENUE L
FORT MADISON, IA 52627-3840
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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