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COMMUNITY PHARMACY OF GOWRIE
CAH161350-00 Stewart Memorial Community Hospital
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Covered Entity Details
Entity Name
Stewart Memorial Community Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161350-00
Entity Address
1301 West Main Street
Lake City, IA 51449-1585
Medicare Provider Number
161350
Participating Start Date
10/1/2011
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
COMMUNITY PHARMACY OF GOWRIE
Pharmacy Address
1800 MAIN ST
GOWRIE, IA 50543
Pharmacy Comments
Contract Details
Approval Date
10/27/2022
Contract Begin Date
11/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JAMES L. HENKENIUS, CFO
(712) 464-3171 Ext: 4200
Contract Pharmacy Representative
Pharma340
Jane Moeller, Pharmacist
(712) 830-5443
Signed By Date
10/27/2022
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