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WELLS HOMETOWN DRUG KEOSAUQUA
CAH161364-00 JEFFERSON COUNTY HEALTH CENTER
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Covered Entity Details
Entity Name
JEFFERSON COUNTY HEALTH CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161364-00
Entity Address
2000 SOUTH MAIN STREET
FAIRFIELD, IA 52556
Medicare Provider Number
161364
Participating Start Date
8/24/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WELLS HOMETOWN DRUG KEOSAUQUA
Pharmacy Address
WELLS BROS. PHARMACY SERVICES VAN BUREN,
1547 BROAD ST
KEOSAUQUA, IA 52565
Pharmacy Comments
Contract Details
Approval Date
7/5/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
BRYAN HUNGER, CEO
(641) 469-4303
Contract Pharmacy Representative
WELLS HOMETOWN DRUG
MYLO WELLS, OWNER - PHARMACIST
(641) 664-3100
Signed By Date
7/5/2023
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