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PROCARE PHARMACY, L.L.C.
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
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203
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
Wellpartner
Dara Pite, Sr. Account Manager
(646) 951-1337
Signed By Date
1/13/2025
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