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HY-VEE PHARMACY FULFILLMENT CENTER 4016
DSH160057A Southeast Iowa Regional Medical Center
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Covered Entity Details
Entity Name
Southeast Iowa Regional Medical Center
Subdivision Name
ORTHOPEDICS-SOUTHEAST IOWA REGIONAL - Orthopedics
Type
Disproportionate Share Hospital
340B ID
DSH160057A
Entity Address
1401 W AGENCY RD
STE 101
WEST BURLINGTON, IA 52655-1647
Medicare Provider Number
160057
Outpatient Facility Provider Number
Participating Start Date
4/1/2022
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY FULFILLMENT CENTER 4016
Pharmacy Address
HY-VEE INC
4707 FLUER DR
DES MOINES, IA 50321
Pharmacy Comments
11-22-2013 Address correction
Contract Details
Approval Date
2/18/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/17/2022
OPA Terminated due to audit finding
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
2/18/2022
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