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CHI HEALTH SPECIALTY PHARMACY
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
CHI HEALTH SPECIALTY PHARMACY
Pharmacy Address
7710 MERCY RD STE 102
OMAHA, NE 68124-2339
Pharmacy Comments
Contract Details
Approval Date
4/4/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
MICHELE PANICUCCI, SENIOR VP/CFO
(319) 272-7359
Contract Pharmacy Representative
Alegent Creighton Health
Michael Tiesi, Regional Senior Director of Pharmacy Services
(402) 717-2614
Signed By Date
4/4/2017
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