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KMART PHARMACY #7767
CAH161323-00 Mitchell County Regional Health Center
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Covered Entity Details
Entity Name
Mitchell County Regional Health Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161323-00
Entity Address
616 N. 8TH STREET
OSAGE, IA 50461
Medicare Provider Number
161323
Participating Start Date
1/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
KMART PHARMACY #7767
Pharmacy Address
1405 S. GRAND
CHARLES CITY, IA 50616
Pharmacy Comments
Contract Details
Approval Date
4/12/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/12/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Gregory J. Burkel, EXECUTIVE FINANCE OFFICER
(641) 732-6070
Contract Pharmacy Representative
Sears
Jennifer Speares, Director of Administration and Compliance
(847) 286-5116
Signed By Date
4/12/2016
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