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THRIFTY WHITE DRUG #747
DSH240100 Sanford Bemidji Medical Center
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Covered Entity Details
Entity Name
Sanford Bemidji Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240100
Entity Address
1300 ANNE STREET NW
BEMIDJI, MN 56601
Medicare Provider Number
240100
Participating Start Date
10/1/2013
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE DRUG #747
Pharmacy Address
30 MAIN STREET SOUTH
P.O. BOX 321
CLEARBROOK, MN 56634
Pharmacy Comments
Contract Details
Approval Date
7/9/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/12/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joy Ellen Johnson, Vice President of Operations
(218) 333-6422
Contract Pharmacy Representative
Thrifty White
Zach Winter, Corporate Manager
(763) 248-7554
Signed By Date
7/9/2019
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