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WAL-MART PHARMACY 10-1546
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
WAL-MART PHARMACY 10-1546
Pharmacy Address
840 SOUTH OAK ST
IOWA FALLS, IA 50126
Pharmacy Comments
Contract Details
Approval Date
10/14/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MICHAEL WHITE, CHIEF FINANCIAL OFFICER
(641) 648-7046
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/14/2014
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