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LEWIS FAMILY DRUG #59
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
LEWIS FAMILY DRUG #59
Pharmacy Address
LEWIS FAMILY DRUG, LLC
143 S MAIN AVE
SIOUX CENTER, IA 51250-1535
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
Joel Luitjens, Pharmacist
(507) 831-4161
Signed By Date
4/15/2013
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