Contract Pharmacy Details

MERCYONE DES MOINES PHARMACY
DSH160083T CATHOLIC HEALTH INITIATIVES - IOWA, CORP

Covered Entity Details

Entity Name

CATHOLIC HEALTH INITIATIVES - IOWA, CORP

Subdivision Name

MERCY ATRIUM IMAGING SUITE

Type

Disproportionate Share Hospital

340B ID

DSH160083T

Entity Address

411 LAUREL ST.
STE A200
DES MOINES, IA 50314

Medicare Provider Number

160083

Outpatient Facility Provider Number

Participating Start Date

4/1/2011

Last Recertification Date

8/17/2016

Entity Termination Date

1/1/2017

Pharmacy Details

Pharmacy Name

MERCYONE DES MOINES PHARMACY

Pharmacy Address

1111 6TH AVE
DES MOINES, IA 50314-2613

Pharmacy Comments

Contract Details

Approval Date

9/5/2012

Contract Begin Date

9/5/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2017

Contacts

Covered Entity Signing Official

Steven Kukla, Director of Pharmacy
(515) 643-4550

Contract Pharmacy Representative

Catholice Health Initiatives, Iowa Corp.
Gregory A. Young, DIRECTOR OF PHARMACY
(515) 247-3262

Signed By Date

8/15/2012

340B Drug Pricing Program Database