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SOUTH SIDE DRUG INC
CAH161367-00 PELLA REGIONAL HEALTH CENTER
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Covered Entity Details
Entity Name
PELLA REGIONAL HEALTH CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161367-00
Entity Address
404 JEFFERSON ST.
PELLA, IA 50219
Medicare Provider Number
161367
Participating Start Date
1/1/2011
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
SOUTH SIDE DRUG INC
Pharmacy Address
SOUTH SIDE DRUG
337 CHURCH ST
OTTUMWA, IA 52501-5250
Pharmacy Comments
Contract Details
Approval Date
4/11/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dawnett Willis, Chief Ancillary Services Officer
(641) 621-2480
Contract Pharmacy Representative
South Side Drug
Mark Frahm, Vice President
(641) 682-3467
Signed By Date
4/11/2018
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