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LEWIS DRUG #10
CAH161336-01 Hegg Memorial Hospital
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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 #10
Pharmacy Address
6109 S LOUISE AVE
SIOUX FALLS, SD 57108
Pharmacy Comments
4/19/11 CORRECTED ADDR (WAS 3109 S. LOUISE AVENUE)
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
Dan Peterson, Pharmacist
(605) 367-2510
Signed By Date
4/15/2013
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