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WAL-MART PHARMACY 10-1621
CAH161377-01 MercyOne Centerville Medical Center
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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
WAL-MART PHARMACY 10-1621
Pharmacy Address
23148 HWY 5
CENTERVILLE, IA 52544
Pharmacy Comments
Contract Details
Approval Date
10/3/2012
Contract Begin Date
10/3/2012
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
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/15/2012
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