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THRIFTY WHITE DRUG #747
CAH241328-00 Sanford Bagley Medical Center
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Covered Entity Details
Entity Name
Sanford Bagley Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241328-00
Entity Address
203 4TH ST. NW
BAGLEY, MN 56621
Medicare Provider Number
241328
Participating Start Date
1/1/2011
Last Recertification Date
8/18/2024
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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