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HY-VEE PHARMACY FULFILLMENT CENTER 4016
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 PHARMACY FULFILLMENT CENTER 4016
Pharmacy Address
HY-VEE INC
4707 FLUER DR
DES MOINES, IA 50321
Pharmacy Comments
11-22-2013 Address correction
Contract Details
Approval Date
7/18/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2017
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
Kristin Williams, Senior VP Pharmacy Operations
(515) 559-5780
Signed By Date
7/18/2016
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