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HIGHLAND PARK CVS, L.L.C.
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
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08654
327 EAST JACKSON ST
MACOMB, IL 61455
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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