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DIPLOMAT SPECIALTY PHARMACY
CAH161363-00 Montgomery County Memorial Hospital
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Covered Entity Details
Entity Name
Montgomery County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161363-00
Entity Address
2301 Eastern Avenue
Red Oak, IA 51566
Medicare Provider Number
161363
Participating Start Date
4/1/2012
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY
Pharmacy Address
4100 S SAGINAW ST
STE D
FLINT, MI 48507-2683
Pharmacy Comments
04/09/2012 update address and name (added suite)
Contract Details
Approval Date
7/14/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/30/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rick J. Leinen, Chief Financial Officer
(712) 623-7150
Contract Pharmacy Representative
Greg Jonas, Manager
(810) 230-5045
Signed By Date
7/14/2015
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