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THRIFTY WHITE PHARMACY #791
CAH241301-00 LAKEWOOD HEALTH CENTER
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Covered Entity Details
Entity Name
LAKEWOOD HEALTH CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241301-00
Entity Address
600 MAIN AVENUE S
BAUDETTE, MN 56623
Medicare Provider Number
241301
Participating Start Date
4/1/2019
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE PHARMACY #791
Pharmacy Address
111 N MAIN AVE
PO BOX 460
BAUDETTE, MN 56623-2466
Pharmacy Comments
Contract Details
Approval Date
4/10/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeffry Alan Stampohar, VP
(218) 634-3401
Contract Pharmacy Representative
Thrifty White
Timothy Weippert, EVP of Pharmacy
(763) 513-4365
Signed By Date
4/10/2019
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