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HULL PHARMACY
CAH161346-00 SIOUX CENTER HEALTH
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Covered Entity Details
Entity Name
SIOUX CENTER HEALTH
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161346-00
Entity Address
1101 9th St SE
SIOUX CENTER, IA 51250-1398
Medicare Provider Number
161346
Participating Start Date
9/28/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
HULL PHARMACY
Pharmacy Address
ATTN RICHARD DYKSTRA
1044 MAIN STREET
BOX 309
HULL, IA 51239
Pharmacy Comments
Contract Details
Approval Date
12/13/2012
Contract Begin Date
12/13/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2016
Ownership change
Contacts
Covered Entity Signing Official
KAYLEEN LEE, CHIEF EXECUTIVE OFFICER
(712) 722-8107
Contract Pharmacy Representative
RICHARD DYKSTRA, PHARMACIST IN CHARGE
(712) 439-1611
Signed By Date
9/25/2012
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