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SUPER SAVER PHARMACY #12
DSH160047 JENNIE EDMUNDSON MEMORIAL
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Covered Entity Details
Entity Name
JENNIE EDMUNDSON MEMORIAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160047
Entity Address
933 EAST PIERCE STREET
COUNCIL BLUFFS, IA 51503
Medicare Provider Number
160047
Participating Start Date
1/1/2016
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
SUPER SAVER PHARMACY #12
Pharmacy Address
1141 N BROADWAY
COUNCIL BLUFFS, IA 51503
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Burd, President & CEO
(712) 396-6064
Contract Pharmacy Representative
B & R Stores-Super Saver
Michael Francis Ryan, Pharmacist in Charge
(712) 322-9019
Signed By Date
1/17/2023
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