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DBA NUCARA PHARMACY #12
DSH160067 MercyOne Waterloo Medical Center
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Covered Entity Details
Entity Name
MercyOne Waterloo Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160067
Entity Address
3421 W 9TH STREET
WATERLOO, IA 50702
Medicare Provider Number
160067
Participating Start Date
1/1/2011
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
DBA NUCARA PHARMACY #12
Pharmacy Address
NUDAK VENTURES LLC
500 2ND ST
TRAER, IA 50675-1139
Pharmacy Comments
Contract Details
Approval Date
8/2/2012
Contract Begin Date
8/2/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michele Panicucci, CFO / Senior Vice President
(319) 272-7359
Contract Pharmacy Representative
Phyllis McKee, Pharmacist In Charge
(319) 478-8711
Signed By Date
6/22/2012
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