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MERCYONE ANKENY PHARMACY
DSH160083H CATHOLIC HEALTH INITIATIVES - IOWA, CORP
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Covered Entity Details
Entity Name
CATHOLIC HEALTH INITIATIVES - IOWA, CORP
Subdivision Name
MERCY WEST RADIOLOGY
Type
Disproportionate Share Hospital
340B ID
DSH160083H
Entity Address
1601 NW 114TH ST
STE 149
CLIVE, IA 50325
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 ANKENY PHARMACY
Pharmacy Address
800 E 1ST ST STE 1800
ANKENY, IA 50021-2100
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
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