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LEWIS FAMILY DRUG #61
CAH161321-00 Avera Merrill Pioneer Hospital
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Covered Entity Details
Entity Name
Avera Merrill Pioneer Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161321-00
Entity Address
1100 S. 10th Ave
Rock Rapids, IA 51246
Medicare Provider Number
161321
Participating Start Date
4/30/2019
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
LEWIS FAMILY DRUG #61
Pharmacy Address
LEWIS FAMILY DRUG LLC
106 N BOONE ST
ROCK RAPIDS, IA 51246-1537
Pharmacy Comments
Contract Details
Approval Date
1/15/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tammy Loosbrock, CEO
(712) 472-2591 Ext: 141
Contract Pharmacy Representative
Lewis Drug
Scott Cross, EVP
(605) 367-2800
Signed By Date
1/15/2015
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