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WAL-MART PHARMACY 10-0886
CAH161302-00 IOWA SPECIALTY HOSPITAL - CLARION
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Covered Entity Details
Entity Name
IOWA SPECIALTY HOSPITAL - CLARION
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161302-00
Entity Address
1316 S Main St
CLARION, IA 50525
Medicare Provider Number
161302
Participating Start Date
9/14/2010
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0886
Pharmacy Address
3036 1ST AVENUE SOUTH
FORT DODGE, IA 50501
Pharmacy Comments
Contract Details
Approval Date
7/11/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/28/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
GREG POLZIN, CFO
(641) 444-5623
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/11/2014
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