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HY-VEE PHARMACY #1863
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
HY-VEE PHARMACY #1863
Pharmacy Address
2181 LOGAN AVENUE
WATERLOO, IA 50703
Pharmacy Comments
Contract Details
Approval Date
3/15/2013
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
Hy- Vee
BOB EGELAND, VP PHARMACY OPERATIONS
(515) 267-2800
Signed By Date
1/18/2013
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