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KMART PHARMACY #7767
CAH161331-00 Mercy Medical Center New Hampton
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Covered Entity Details
Entity Name
Mercy Medical Center New Hampton
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161331-00
Entity Address
308 NORTH MAPLE AVENUE
NEW HAMPTON, IA 50659
Medicare Provider Number
161331
Participating Start Date
4/1/2011
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
KMART PHARMACY #7767
Pharmacy Address
1405 S. GRAND
CHARLES CITY, IA 50616
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/10/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JENNIFER RAPENSKE, REGIONAL CFO
(641) 394-1682
Contract Pharmacy Representative
Sears
Jennifer Speares, Director of Administration and Compliance
(847) 286-5116
Signed By Date
4/15/2016
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