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GRAND ST. PAUL CVS, L.L.C.
DSH240100 Sanford Bemidji Medical Center
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Covered Entity Details
Entity Name
Sanford Bemidji Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240100
Entity Address
1300 ANNE STREET NW
BEMIDJI, MN 56601
Medicare Provider Number
240100
Participating Start Date
10/1/2013
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
GRAND ST. PAUL CVS, L.L.C.
Pharmacy Address
CVS PHARMACY # 16184
2100 PAUL BUNYAN DR NW
BEMIDJI, MN 56601
Pharmacy Comments
Contract Details
Approval Date
10/12/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CRAIG O. BOYER, Vice President of Finance
(218) 333-5508
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/12/2018
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