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HY-VEE PHARMAACY 1400
CAH241348-00 AVERA TYLER
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Covered Entity Details
Entity Name
AVERA TYLER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241348-00
Entity Address
240 WILLOW STREET
TYLER, MN 56178
Medicare Provider Number
241348
Participating Start Date
4/1/2013
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMAACY 1400
Pharmacy Address
900 E. MAIN
MARSHALL, MN 56258
Pharmacy Comments
Contract Details
Approval Date
4/15/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/4/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DALE KRUGER, CEO
(507) 247-2351
Contract Pharmacy Representative
ROBERT EGELAND, VICE PRESIDENT/PHARMACY OPERATIONS
(515) 267-2800
Signed By Date
4/15/2013
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