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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 07455
111 W RIDGEWAY AVE
WATERLOO, IA 50701-4233
Pharmacy Comments
Contract Details
Approval Date
10/25/2012
Contract Begin Date
10/25/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MICHELE PANICUCCI, SENIOR VP/CFO
(319) 272-7359
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/12/2012
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