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WAL-MART PHARMACY 10-1546
DSH160064 MercyOne North Iowa Medical Center
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Covered Entity Details
Entity Name
MercyOne North Iowa Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160064
Entity Address
1000 4TH STREET SW
MASON CITY, IA 50401
Medicare Provider Number
160064
Participating Start Date
10/1/2019
Last Recertification Date
8/19/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1546
Pharmacy Address
840 SOUTH OAK ST
IOWA FALLS, IA 50126
Pharmacy Comments
Contract Details
Approval Date
11/23/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
DANETTE ZOOK, RHM VP Finance
(641) 428-7989
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
11/23/2016
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