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HY-VEE PHARMACY
DSH160122 Fort Madison Community Hospital
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Covered Entity Details
Entity Name
Fort Madison Community Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160122
Entity Address
5445 Avenue O
Fort Madison, IA 52627
Medicare Provider Number
160122
Participating Start Date
7/1/2014
Last Recertification Date
8/17/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY
Pharmacy Address
3111 MAIN
KEOKUK, IA 52632
Pharmacy Comments
Contract Details
Approval Date
10/13/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Brad Kokjohn, CFO
(319) 376-2125
Contract Pharmacy Representative
Hy-Vee Inc
Matt Pertzborn, Director, Pharm Bus Dvpt
(515) 559-5761
Signed By Date
10/13/2016
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