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THRIFTY WHITE PHARMACY #779
CAH241370-02 ST. GABRIEL'S HOSPITAL
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Covered Entity Details
Entity Name
ST. GABRIEL'S HOSPITAL
Subdivision Name
FAMILY MEDICAL CENTER
Type
Critical Access Hospital
340B ID
CAH241370-02
Entity Address
811 2ND ST. S.E.
LITTLE FALLS, MN 56345
Medicare Provider Number
241370
Outpatient Facility Provider Number
Participating Start Date
10/1/2012
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE PHARMACY #779
Pharmacy Address
112A MAIN ST S
PO BOX 279
PIERZ, MN 56364-4400
Pharmacy Comments
Contract Details
Approval Date
7/18/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
STEVEN SMITH, President
(320) 631-5600
Contract Pharmacy Representative
Thrifty White
Zach Winter, Corporate Manager
(763) 248-7554
Signed By Date
7/18/2018
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