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MERCYONE DES MOINES PHARMACY
DSH160083G CATHOLIC HEALTH INITIATIVES - IOWA, CORP
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Covered Entity Details
Entity Name
CATHOLIC HEALTH INITIATIVES - IOWA, CORP
Subdivision Name
MERCYONE DES MOINES FIRST STEP RECOVERY
Type
Disproportionate Share Hospital
340B ID
DSH160083G
Entity Address
1750 48TH ST
STE 2
DES MOINES, IA 50310-1988
Medicare Provider Number
160083
Outpatient Facility Provider Number
Participating Start Date
4/1/2011
Last Recertification Date
8/27/2021
Entity Termination Date
7/1/2022
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
7/1/2022
Covered Entity Terminated
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
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