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HY-VEE PHARMACY FULFILLMENT CENTER 4016
CAH161375-00 BUENA VISTA REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
BUENA VISTA REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161375-00
Entity Address
1525 W. 5TH ST.
STORM LAKE, IA 50588
Medicare Provider Number
161375
Participating Start Date
8/18/2010
Last Recertification Date
8/26/2024
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
4/15/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/10/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Krista L. Ketcham, Chief Financial Officer
(712) 213-8603
Contract Pharmacy Representative
Hy-Vee Inc
Matt Pertzborn, Director, Pharm Bus Dvpt
(515) 559-5761
Signed By Date
4/15/2014
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