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GRX HOLDINGS, LLC
DSH160082 IOWA METHODIST MEDICAL CENTER
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Covered Entity Details
Entity Name
IOWA METHODIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160082
Entity Address
1200 PLEASANT STREET
DES MOINES, IA 50309
Medicare Provider Number
160082
Participating Start Date
7/1/2017
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
GRX HOLDINGS, LLC
Pharmacy Address
MEDICAP PHARMACY
504 14TH STREET
PO BOX 369
DALLAS CENTER, IA 50063-2075
Pharmacy Comments
Contract Details
Approval Date
10/11/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/5/2025
Pharmacy closed
Contacts
Covered Entity Signing Official
Eric Lothe, SVP/COO
(515) 241-5858
Contract Pharmacy Representative
GRX Holdings, LLC
Katie Thaut, Vice President of Operations
(515) 440-1270
Signed By Date
10/11/2022
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