Contract Pharmacy Details

SHOPKO PHARMACY #2142
DSH160122 Fort Madison Community Hospital

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

SHOPKO PHARMACY #2142

Pharmacy Address

SHOPKO PHARMACY
4810 AVENUE O
FORT MADISON, IA 52627

Pharmacy Comments

Contract Details

Approval Date

10/17/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/4/2021
CE terminated due to audit finding

Contacts

Covered Entity Signing Official

Brad Kokjohn, CFO
(319) 376-2125

Contract Pharmacy Representative

ShopKo
Lorie Neumann, Contracting & Compliance
(920) 429-4726

Signed By Date

10/17/2016

340B Drug Pricing Program Database