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HY-VEE PHARMACY FULFILLMENT CENTER 4016
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 FULFILLMENT CENTER 4016
Pharmacy Address
HY-VEE INC
4707 FLUER DR
DES MOINES, IA 50321
Pharmacy Comments
11-22-2013 Address correction
Contract Details
Approval Date
4/15/2014
Contract Begin Date
7/1/2014
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 Inc
Matt Pertzborn, Director, Pharm Bus Dvpt
(515) 559-5761
Signed By Date
4/15/2014
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