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CENTRACARE PHARMACY NORTHWAY
DSH240036 ST. CLOUD HOSPITAL
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Covered Entity Details
Entity Name
ST. CLOUD HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240036
Entity Address
1406 6TH AVENUE NORTH
Saint Cloud, MN 56303
Medicare Provider Number
240036
Participating Start Date
7/1/2016
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
CENTRACARE PHARMACY NORTHWAY
Pharmacy Address
1555 NORTHWAY DR STE 150
SAINT CLOUD, MN 56303-4912
Pharmacy Comments
Contract Details
Approval Date
7/12/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kurt Tyler Otto, Vice President Operations, Specialty Division
(320) 251-2700 Ext: 55971
Contract Pharmacy Representative
CentraCare
Keith Karsky, Coordinator, Retail Pharmacy Services
(320) 229-5199 Ext: 70580
Signed By Date
7/12/2018
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