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WALGREEN CO.
DSH160153 MERCYONE SIOUXLAND MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCYONE SIOUXLAND MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160153
Entity Address
801 FIFTH STREET
SIOUX CITY, IA 51101
Medicare Provider Number
160153
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #15647
1900 HAMILTON BLVD
SIOUX CITY, IA 51104
Pharmacy Comments
Contract Details
Approval Date
1/17/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jesica Hanson, VP of Finance
(712) 279-5850
Contract Pharmacy Representative
Walgreens
Chrysta Nikols, 340B Client Relationship Analyst
(847) 315-5335
Signed By Date
1/13/2025
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