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HY-VEE PHACY #1136
DSH160082 IOWA METHODIST MEDICAL CENTER
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Covered Entity Details
Entity Name
IOWA METHODIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160082
Entity Address
1200 PLEASANT STREET
DES MOINES, IA 50309
Medicare Provider Number
160082
Participating Start Date
7/1/2017
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHACY #1136
Pharmacy Address
3330 MARTIN LUTHER KING JR PKY
DES MOINES, IA 50310
Pharmacy Comments
Contract Details
Approval Date
7/6/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Eric Lothe, SVP/COO
(515) 241-5858
Contract Pharmacy Representative
Hy-vee Inc.
Marshall Sanders, 340B Program Manager
(515) 267-6009
Signed By Date
7/6/2017
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