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HY-VEE PHARMACY FULFILLMENT CENTER 4016
DSH140280 TRINITY ROCK ISLAND
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Covered Entity Details
Entity Name
TRINITY ROCK ISLAND
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140280
Entity Address
2701 17TH STREET
ROCK ISLAND, IL 61201
Medicare Provider Number
140280
Participating Start Date
7/1/2016
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY FULFILLMENT CENTER 4016
Pharmacy Address
HY-VEE INC
4707 FLUER DR
DES MOINES, IA 50321
Pharmacy Comments
11-22-2013 Address correction
Contract Details
Approval Date
10/13/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/24/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dave Dellitt, Chief Financial Officer
(309) 779-2218
Contract Pharmacy Representative
Hy-vee Inc.
Marshall Sanders, 340B Program Manager
(515) 267-6009
Signed By Date
10/13/2016
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