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SHOPKO PHARMACY #2733
CAH241379-00 Prairie Ridge Hospital and Health Services
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Covered Entity Details
Entity Name
Prairie Ridge Hospital and Health Services
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241379-00
Entity Address
1411 Hwy 79 East
Elbow Lake, MN 56531
Medicare Provider Number
241379
Participating Start Date
1/1/2014
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2733
Pharmacy Address
226 E LINCOLN AVE
FERGUS FALLS, MN 56537
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/28/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Danielle Janice Lesmeister, Chief Executive Officer
(218) 685-7344
Contract Pharmacy Representative
Shopko Pharmacy
Debi Danbury, 340B Program Manager
(920) 429-7613
Signed By Date
10/15/2018
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