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HY-VEE PHARMACY #1241
CAH161374-00 SHELBY CO CHRIS A MYRTUE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SHELBY CO CHRIS A MYRTUE MEMORIAL HOSPITAL
Subdivision Name
DBA MYRTUE MEDICAL CENTER
Type
Critical Access Hospital
340B ID
CAH161374-00
Entity Address
1213 GARFIELD AVE
HARLAN, IA 51537
Medicare Provider Number
161374
Participating Start Date
4/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY #1241
Pharmacy Address
2003 CHATBURN
P.O. BOX 719
HARLAN, IA 51537-0069
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
7/12/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Barry Jacobsen, CEO
(712) 755-4315
Contract Pharmacy Representative
Hy- Vee
BOB EGELAND, VP PHARMACY OPERATIONS
(515) 267-2800
Signed By Date
10/2/2013
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