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Hy-Vee Pharmacy Fulfillment Center #4016
CAH161363-00 Montgomery County Memorial Hospital
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Covered Entity Details
Entity Name
Montgomery County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161363-00
Entity Address
2301 Eastern Avenue
Red Oak, IA 51566
Medicare Provider Number
161363
Participating Start Date
4/1/2012
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
Hy-Vee Pharmacy Fulfillment Center #4016
Pharmacy Address
Hy-Vee Inc
4707 Fleur Dr
Des Moines, IA 50321
Pharmacy Comments
Contract Details
Approval Date
4/11/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rick J. Leinen, Chief Financial Officer
(712) 623-7150
Contract Pharmacy Representative
Hy-Vee, Inc
Ashley Plum, 340B Coordinator
(515) 559-5708
Signed By Date
4/11/2022
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