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THRIFTY WHITE PHARMACY #754
CAH241309-00 PINE MEDICAL CENTER
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Covered Entity Details
Entity Name
PINE MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241309-00
Entity Address
705 LUNDORFF DR
SANDSTONE, MN 55072
Medicare Provider Number
241309
Participating Start Date
7/1/2011
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE PHARMACY #754
Pharmacy Address
60 NORTH ARROWHEAD LN
P.O. BOX 719
MOOSE LAKE, MN 55767-9453
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Scott Nigon, CFO
(218) 786-3212
Contract Pharmacy Representative
Thrifty White
Zach Winter, Corporate Manager
(763) 248-7554
Signed By Date
4/15/2019
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