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COBORN'S PHARMACY #2035
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
COBORN'S PHARMACY #2035
Pharmacy Address
900 COOPER AVE S
SAINT CLOUD, MN 56301-6267
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
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
Coborn's
Jim Cox, 340B Program Director
(320) 257-5505
Signed By Date
1/15/2019
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