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CLINIC PHARMACY OF CARROLL
SCH160005-00 ST. ANTHONY REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
ST. ANTHONY REGIONAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH160005-00
Entity Address
311 SOUTH CLARK STREET
CARROLL, IA 51401
Medicare Provider Number
160005
Participating Start Date
10/1/2017
Last Recertification Date
9/12/2023
Entity Termination Date
5/22/2024
Pharmacy Details
Pharmacy Name
CLINIC PHARMACY OF CARROLL
Pharmacy Address
OWNED &OPERATED BY LINCOLN HIGHWAY PHARM
405 SOUTH CLARK STREET
SUITE 102
CARROLL, IA 51401
Pharmacy Comments
Contract Details
Approval Date
10/2/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Munson, Vice President & CFO
(712) 794-5115
Contract Pharmacy Representative
Clinic Pharmacy of Carroll
Jerry Fleshner, Owner
(712) 792-5393
Signed By Date
10/2/2017
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