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WALGREEN CO.
DSH160057AE Southeast Iowa Regional Medical Center
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Covered Entity Details
Entity Name
Southeast Iowa Regional Medical Center
Subdivision Name
RADIATION ONCOLOGY-SOUTHEAST IOWA R - Radiation Oncology
Type
Disproportionate Share Hospital
340B ID
DSH160057AE
Entity Address
1315 W AGENCY RD
STE 151
WEST BURLINGTON, IA 52655-1654
Medicare Provider Number
160057
Outpatient Facility Provider Number
Participating Start Date
4/1/2022
Last Recertification Date
8/12/2024
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
2/18/2022
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
2/18/2022
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