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HY-VEE, INC.
DSH240022 SANFORD WORTHINGTON MEDICAL CENTER
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Covered Entity Details
Entity Name
SANFORD WORTHINGTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240022
Entity Address
1018 6TH AVENUE
WORTHINGTON, MN 56187-0097
Medicare Provider Number
240022
Participating Start Date
1/1/2010
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
HY-VEE, INC.
Pharmacy Address
DBA: HY-VEE PHARMACY 1897
1235 OXFORD STREET
WORTHINGTON, MN 56187
Pharmacy Comments
Contract Details
Approval Date
4/25/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
LINDA WAGNER, Director of Fiscal Services
(507) 372-2941 Ext: 3112
Contract Pharmacy Representative
Hy- Vee
BOB EGELAND, VP PHARMACY OPERATIONS
(515) 267-2800
Signed By Date
4/25/2013
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