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WAL-MART PHARMACY 10-1496
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
WAL-MART PHARMACY 10-1496
Pharmacy Address
1334 FLAMMANG DRIVE
WATERLOO, IA 50702
Pharmacy Comments
Contract Details
Approval Date
9/10/2012
Contract Begin Date
9/10/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michele Panicucci, CFO / Senior Vice President
(319) 272-7359
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
8/20/2012
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