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HY-VEE PHARMACY (1353)
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 (1353)
Pharmacy Address
809 WEST ROCK ISLAND ST
KNOXVILLE, IA 50138
Pharmacy Comments
Contract Details
Approval Date
7/16/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/28/2016
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
7/16/2013
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