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SCOTT PHARMACY
DSH160110 Allen Memorial Hospital Corporation
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Covered Entity Details
Entity Name
Allen Memorial Hospital Corporation
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160110
Entity Address
1825 Logan Avenue
Waterloo, IA 50703-1916
Medicare Provider Number
160110
Participating Start Date
1/1/2014
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
SCOTT PHARMACY
Pharmacy Address
238 S MAIN ST
PO BOX 188
FAYETTE, IA 52142
Pharmacy Comments
Contract Details
Approval Date
1/10/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jennifer A Friedly, President
(319) 235-3997
Contract Pharmacy Representative
Scott Pharmacy
David J Scott, PharmD, MBA
(563) 425-4530
Signed By Date
1/10/2025
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