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SHOPKO PHARMACY #2561
DSH240187 HUTCHINSON HEALTH
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Covered Entity Details
Entity Name
HUTCHINSON HEALTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240187
Entity Address
1095 HIGHWAY 15 SOUTH
HUTCHINSON, MN 55350
Medicare Provider Number
240187
Participating Start Date
7/1/2017
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2561
Pharmacy Address
145 BROADWAY AVE N
COKATO, MN 55321
Pharmacy Comments
Contract Details
Approval Date
10/12/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Pamela J. Larson, CFO
(320) 484-4472
Contract Pharmacy Representative
Shopko Pharmacy
Debi Danbury, 340B Program Manager
(920) 429-7613
Signed By Date
10/12/2018
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