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SHOPKO PHARMACY #2668
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
SHOPKO PHARMACY #2668
Pharmacy Address
660 W MILWAUKEE ST
NEW HAMPTON, IA 50659
Pharmacy Comments
Contract Details
Approval Date
4/14/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Gregory J. Burkel, EXECUTIVE FINANCE OFFICER
(641) 732-6070
Contract Pharmacy Representative
ShopKo
Lorie Neumann, Contracting & Compliance
(920) 429-4726
Signed By Date
4/14/2016
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