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HY-VEE PHARMACY #1036
CAH261328-00 NORTHWEST MEDICAL CENTER ASSOCIATION, INC.
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Covered Entity Details
Entity Name
NORTHWEST MEDICAL CENTER ASSOCIATION, INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261328-00
Entity Address
705 N. COLLEGE
ALBANY, MO 64402-1433
Medicare Provider Number
261328
Participating Start Date
9/24/2010
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY #1036
Pharmacy Address
1104 S 25TH STREET
BOX 47
BETHANY, MO 64424
Pharmacy Comments
Pharmacy located at 710 main Princeton MO has the same name.
Contract Details
Approval Date
12/6/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/15/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JON David DOOLITTLE, PRESIDENT & CEO
(660) 726-3941 Ext: 1177
Contract Pharmacy Representative
Hy- Vee
BOB EGELAND, VP PHARMACY OPERATIONS
(515) 267-2800
Signed By Date
10/11/2012
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