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ESSENTIA HEALTH PEQUOT LAKES PHARMACY
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
ESSENTIA HEALTH PEQUOT LAKES PHARMACY
Pharmacy Address
30581 PATRIOT AVE
SUITE A
PEQUOT LAKES, MN 56472
Pharmacy Comments
Contract Details
Approval Date
7/10/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ryan Hill, Administrator
(218) 784-5201
Contract Pharmacy Representative
Essentia Health
Kenzie Hohman, Senior Director of Ambulatory Pharmacy
(715) 817-7171
Signed By Date
7/10/2019
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