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HY-VEE PHARMACY
CAH161334-00 Humboldt County Memorial Hospital
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Covered Entity Details
Entity Name
Humboldt County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161334-00
Entity Address
1000 North 15th Street
Humboldt, IA 50548
Medicare Provider Number
161334
Participating Start Date
10/1/2012
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY
Pharmacy Address
611 10TH AVE. N.
HUMBOLDT, IA 50548
Pharmacy Comments
Contract Details
Approval Date
7/15/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/23/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jim Atty, CEO
(515) 332-4200
Contract Pharmacy Representative
Hy-Vee Inc
Matt Pertzborn, Director, Pharm Bus Dvpt
(515) 559-5761
Signed By Date
7/15/2013
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