Contract Pharmacy Details

LEWIS DRUG #5
CAH161336-01 Hegg Memorial Hospital

Covered Entity Details

Entity Name

Hegg Memorial Hospital

Subdivision Name

Hegg Medical Clinic Avera

Type

Critical Access Hospital

340B ID

CAH161336-01

Entity Address

1200 21st Avenue
Rock Valley, IA 51247

Medicare Provider Number

161336

Outpatient Facility Provider Number

Participating Start Date

4/1/2012

Last Recertification Date

8/28/2018

Entity Termination Date

4/1/2019

Pharmacy Details

Pharmacy Name

LEWIS DRUG #5

Pharmacy Address

741 S WASHINGTON AVE
MADISON, SD 57042-3409

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

4/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Glenn Zevenbergen, CEO
(712) 476-8009

Contract Pharmacy Representative

Lewis
Rachel Schardin, Pharmacist
(605) 256-3571

Signed By Date

4/15/2013