Contract Pharmacy Details

LEWIS DRUG #12
CAH161336-00 Hegg Memorial Hospital

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

LEWIS DRUG #12

Pharmacy Address

910 22ND AVE S
BROOKINGS, SD 57006-2830

Pharmacy Comments

Contract Details

Approval Date

4/15/2013

Contract Begin Date

7/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/20/2017
Agreement registered in error

Contacts

Covered Entity Signing Official

Glenn Zevenbergen, CEO
(712) 476-8009

Contract Pharmacy Representative

Ken Main, Pharmacist
(605) 692-8881

Signed By Date

4/15/2013