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HARTIG DRUG STORE #5
CAH141302-00 Midwest Medical Center
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Covered Entity Details
Entity Name
Midwest Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141302-00
Entity Address
One Medical Center Drive
Galena, IL 61036
Medicare Provider Number
141302
Participating Start Date
1/1/2014
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
HARTIG DRUG STORE #5
Pharmacy Address
11002 BARTEL BLVD
GALENA, IL 61036-8215
Pharmacy Comments
Contract Details
Approval Date
1/15/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tracy Bauer, CEO
(815) 776-7266
Contract Pharmacy Representative
Hartig Drug
Keith Bibelhausen, President
(563) 588-8700
Signed By Date
1/15/2014
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