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THRIFTY WHITE PHARMACY #792
DSH240084 ESSENTIA HEALTH VIRGINIA
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Covered Entity Details
Entity Name
ESSENTIA HEALTH VIRGINIA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240084
Entity Address
901 9TH STREET NORTH
VIRGINIA, MN 55792-2398
Medicare Provider Number
240084
Participating Start Date
1/1/2021
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE PHARMACY #792
Pharmacy Address
221 KENNEDY MEMORIAL DR.
SUITE A
HOYT LAKES, MN 55750-1141
Pharmacy Comments
Contract Details
Approval Date
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Sam Stone, COO
(218) 742-8600 Ext: 2496
Contract Pharmacy Representative
Thrifty White
Zach Winter, Corporate Manager
(763) 248-7554
Signed By Date
4/12/2019
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