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HY-VEE PHARMACY (1516)
CAH161367-00 PELLA REGIONAL HEALTH CENTER
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Covered Entity Details
Entity Name
PELLA REGIONAL HEALTH CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161367-00
Entity Address
404 JEFFERSON ST.
PELLA, IA 50219
Medicare Provider Number
161367
Participating Start Date
1/1/2011
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY (1516)
Pharmacy Address
118 SE 9TH STREET
PELLA, IA 50219
Pharmacy Comments
Contract Details
Approval Date
3/14/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/15/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ROBERT KROESE, CHIEF EXECUTIVE OFFICER
(641) 628-6604 Ext: 6604
Contract Pharmacy Representative
Hy- Vee
BOB EGELAND, VP PHARMACY OPERATIONS
(515) 267-2800
Signed By Date
1/29/2013
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