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WAL-MART PHARMACY 10-1546
SCH160064-00 MERCYONE NORTH IOWA MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCYONE NORTH IOWA MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH160064-00
Entity Address
1000 4TH STREET SW
MASON CITY, IA 50401
Medicare Provider Number
160064
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1546
Pharmacy Address
840 SOUTH OAK ST
IOWA FALLS, IA 50126
Pharmacy Comments
Contract Details
Approval Date
10/1/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
DANETTE ZOOK, RHM VP Finance
(641) 428-7989
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/1/2015
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