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SCOTT PHARMACY
CAH161316-00 Palmer Lutheran Health Center
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Covered Entity Details
Entity Name
Palmer Lutheran Health Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161316-00
Entity Address
112 Jefferson Street
West Union, IA 52175
Medicare Provider Number
161316
Participating Start Date
4/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
SCOTT PHARMACY
Pharmacy Address
238 S MAIN ST
PO BOX 188
FAYETTE, IA 52142
Pharmacy Comments
Contract Details
Approval Date
7/12/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brenda Moser, Finance Administrator
(563) 422-3811 Ext: 64783
Contract Pharmacy Representative
Scott Pharmacy
David Scott, Pharmacist
(563) 425-4530
Signed By Date
7/12/2017
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