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MERCYONE CLIVE PHARMACY
DSH160083 CATHOLIC HEALTH INITIATIVES - IOWA, CORP
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Covered Entity Details
Entity Name
CATHOLIC HEALTH INITIATIVES - IOWA, CORP
Subdivision Name
MERCYONE DES MOINES MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH160083
Entity Address
1111 6th Avenue
DES MOINES, IA 50314-2610
Medicare Provider Number
160083
Participating Start Date
4/1/2011
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
MERCYONE CLIVE PHARMACY
Pharmacy Address
1601 NW 114TH ST STE 234
CLIVE, IA 50325-7007
Pharmacy Comments
Contract Details
Approval Date
7/27/2011
Contract Begin Date
7/27/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steven Kukla, Sr. VP & CFO
(515) 643-4550
Contract Pharmacy Representative
Catholice Health Initiatives, Iowa Corp.
Gregory A. Young, DIRECTOR OF PHARMACY
(515) 247-3262
Signed By Date
7/20/2011
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