Contract Pharmacy Details

OWL PHARMACY
CAH161377-01 MercyOne Centerville Medical Center

Covered Entity Details

Entity Name

MercyOne Centerville Medical Center

Subdivision Name

MERCY RURAL HEALTH CLINIC DBA MercyOne Centerville Medical Clinic

Type

Critical Access Hospital

340B ID

CAH161377-01

Entity Address

19942 ST. JOSEPH'S DRIVE
CENTERVILLE, IA 52544

Medicare Provider Number

161377

Outpatient Facility Provider Number

168533

Participating Start Date

7/1/2011

Last Recertification Date

8/12/2024

Pharmacy Details

Pharmacy Name

OWL PHARMACY

Pharmacy Address

213 N 13TH ST
CENTERVILLE, IA 52544-1707

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

2/22/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Lori Rathbun, CFO
(641) 437-3442

Contract Pharmacy Representative

Owl Pharmacy
FRANK REZNICEK, OWNER/OPERATOR
(641) 895-6368

Signed By Date

9/7/2012

340B Drug Pricing Program Database