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SUPER SAVER PHARMACY #12
DSH160028 ALEGENT HEALTH-BERGAN MERCY HEALTH SYSTEM d/b/a CHI Health Mercy Council Bluffs
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Covered Entity Details
Entity Name
ALEGENT HEALTH-BERGAN MERCY HEALTH SYSTEM d/b/a CHI Health Mercy Council Bluffs
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160028
Entity Address
800 MERCY DRIVE
COUNCIL BLUFFS, IA 51503
Medicare Provider Number
160028
Participating Start Date
4/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SUPER SAVER PHARMACY #12
Pharmacy Address
1141 N BROADWAY
COUNCIL BLUFFS, IA 51503
Pharmacy Comments
Contract Details
Approval Date
3/20/2012
Contract Begin Date
3/20/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rick Miller, SVP CQO
(402) 343-4380
Contract Pharmacy Representative
Pat Raybould, President
(402) 464-6297
Signed By Date
2/23/2012
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