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SHOPKO PHARMACY #2689
CAH161358-00 Wayne County Hospital
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Covered Entity Details
Entity Name
Wayne County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161358-00
Entity Address
417 S East Street
Corydon, IA 50060
Medicare Provider Number
161358
Participating Start Date
4/1/2013
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2689
Pharmacy Address
201 N FILLMORE ST
MOUNT AYR, IA 50854
Pharmacy Comments
Contract Details
Approval Date
7/7/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Denise Hook, CFO
(641) 872-5277
Contract Pharmacy Representative
Shopko
Tad Schilke, Director of Rx Merchandising & Marketing
(920) 429-7628
Signed By Date
7/7/2014
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