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LEWIS FAMILY DRUG #77
CAH241365-00 CENTRACARE HEALTH - BENSON, LLC
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Covered Entity Details
Entity Name
CENTRACARE HEALTH - BENSON, LLC
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241365-00
Entity Address
1815 Wisconsin Avenue
Benson, MN 56215
Medicare Provider Number
241365
Participating Start Date
7/1/2012
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
LEWIS FAMILY DRUG #77
Pharmacy Address
1805 MINNESOTA AVE STE 2
BENSON, MN 56215-1779
Pharmacy Comments
Contract Details
Approval Date
7/9/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/20/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Dan Enderson, CFO
(320) 843-4232
Contract Pharmacy Representative
Lewis Family Drug
Adam Kolander, PharmD
(320) 842-3221
Signed By Date
7/9/2018
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