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WAL-MART PHARMACY 10-1496
CAH161338-00 MercyOne Oelwein Medical Center
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Covered Entity Details
Entity Name
MercyOne Oelwein Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161338-00
Entity Address
201 8TH AVE
OELWEIN, IA 50662-2447
Medicare Provider Number
161338
Participating Start Date
9/30/2010
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1496
Pharmacy Address
1334 FLAMMANG DRIVE
WATERLOO, IA 50702
Pharmacy Comments
Contract Details
Approval Date
2/20/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/31/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MICHELE PANICUCCI, SENIOR VP/CFO
(319) 272-7359
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/17/2013
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