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IOWA CVS PHARMACY, L.L.C.
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
IOWA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08546
205 FRANKLIN STREET
WATERLOO, IA 50703
Pharmacy Comments
Contract Details
Approval Date
10/2/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/31/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
MICHELE PANICUCCI, SENIOR VP/CFO
(319) 272-7359
Contract Pharmacy Representative
Scott Tierney, Senior Director, Payer Relations
(401) 770-2762
Signed By Date
10/2/2013
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