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WAL-MART PHARMACY 10-1528
DSH160045 ST LUKES METHODIST HOSPITAL
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Covered Entity Details
Entity Name
ST LUKES METHODIST HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160045
Entity Address
1026 A AVENUE NE
CEDAR RAPIDS, IA 52402-3026
Medicare Provider Number
160045
Participating Start Date
1/1/2014
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1528
Pharmacy Address
2645 BLAIRS FERRY RD
CEDAR RAPIDS, IA 52402
Pharmacy Comments
Contract Details
Approval Date
7/14/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brian Lannie Checketts, VICE PRESIDENT/CFO
(319) 369-7094
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/14/2016
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