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HY-VEE PHARMACY (1295)
CAH161380-00 ELLSWORTH MUNICIPAL HOSPITAL
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Covered Entity Details
Entity Name
ELLSWORTH MUNICIPAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161380-00
Entity Address
920 S OAK ST
DBA HANSEN FAMILY HOSPITAL
IOWA FALLS, IA 50126-9506
Medicare Provider Number
161380
Participating Start Date
9/1/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY (1295)
Pharmacy Address
632 S. OAK RIVER HILLS
IOWA FALLS, IA 50126
Pharmacy Comments
Contract Details
Approval Date
7/15/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/13/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MICHAEL WHITE, CHIEF FINANCIAL OFFICER
(641) 648-7046
Contract Pharmacy Representative
Hy-Vee Inc
Matt Pertzborn, Director, Pharm Bus Dvpt
(515) 559-5761
Signed By Date
7/15/2014
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