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MERCYONE CLIVE PHARMACY
DSH160083Q CATHOLIC HEALTH INITIATIVES - IOWA, CORP
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Covered Entity Details
Entity Name
CATHOLIC HEALTH INITIATIVES - IOWA, CORP
Subdivision Name
MERCY RADIOLOGY CENTER
Type
Disproportionate Share Hospital
340B ID
DSH160083Q
Entity Address
12495 UNIVERSITY AVE
STE 210
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 CLIVE PHARMACY
Pharmacy Address
1601 NW 114TH ST STE 234
CLIVE, IA 50325-7007
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
David Sinnwell, CEO
(515) 278-1657
Signed By Date
8/15/2012
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