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THRIFTY WHITE PHARMACY #023
DSH240101 ST MARYS REGIONAL HEALTH CENTER
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Covered Entity Details
Entity Name
ST MARYS REGIONAL HEALTH CENTER
Subdivision Name
Essentia Health St. Mary's
Type
Disproportionate Share Hospital
340B ID
DSH240101
Entity Address
1027 WASHINGTON AVE
DETROIT LAKES, MN 56501
Medicare Provider Number
240101
Participating Start Date
1/1/2015
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE PHARMACY #023
Pharmacy Address
321 HIGHWAY 10 W
DETROIT LAKES, MN 56501-3046
Pharmacy Comments
Contract Details
Approval Date
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Peter Jacobson, VP of Operations
(218) 847-0888
Contract Pharmacy Representative
Thrifty White
Zach Winter, Corporate Manager
(763) 248-7554
Signed By Date
4/12/2019
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