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HY-VEE PHARMAACY 1400
CAH241343-00 AVERA GRANITE FALLS
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Covered Entity Details
Entity Name
AVERA GRANITE FALLS
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241343-00
Entity Address
345 10TH AVE
GRANITE FALLS, MN 56241
Medicare Provider Number
241343
Participating Start Date
9/29/2010
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMAACY 1400
Pharmacy Address
900 E. MAIN
MARSHALL, MN 56258
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
Tom Kooiman, ADMINISTRATOR/CEO
(320) 564-6201
Contract Pharmacy Representative
Hy-vee Inc.
Marshall Sanders, 340B Program Manager
(515) 267-6009
Signed By Date
4/12/2019
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