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MEDICAP PHARMACY
CAH161372-00 BOONE COUNTY HOSPITAL
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Covered Entity Details
Entity Name
BOONE COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161372-00
Entity Address
1015 UNION STREET
BOONE, IA 50036
Medicare Provider Number
161372
Participating Start Date
9/2/2010
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
MEDICAP PHARMACY
Pharmacy Address
GRX HOLDINGS, LLC
403 STORY STREET
BOONE, IA 50036-3533
Pharmacy Comments
Contract Details
Approval Date
10/14/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/30/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joe Smith, Chief Executive Officer
(515) 433-8480
Contract Pharmacy Representative
Karen Merrill, Pharmacy Manager
(515) 280-2910
Signed By Date
10/14/2016
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