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HULL PHARMACY
CAH161336-00 Hegg Memorial Hospital
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Covered Entity Details
Entity Name
Hegg Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161336-00
Entity Address
1202 21st Ave
Rock Valley, IA 51247
Medicare Provider Number
161336
Participating Start Date
10/1/2011
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
HULL PHARMACY
Pharmacy Address
ATTN RICHARD DYKSTRA
1044 MAIN STREET
BOX 309
HULL, IA 51239
Pharmacy Comments
Contract Details
Approval Date
11/29/2012
Contract Begin Date
11/29/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2016
Ownership change
Contacts
Covered Entity Signing Official
GLENN ZEVENBERGEN, CEO
(712) 476-8009
Contract Pharmacy Representative
RICHARD DYKSTRA, PHARMACIST IN CHARGE
(712) 439-1611
Signed By Date
9/24/2012
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