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ESSENTIA HEALTH PEQUOT LAKES PHARMACY
SCH240075-00 ST JOSEPHS MEDICAL CENTER
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Covered Entity Details
Entity Name
ST JOSEPHS MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH240075-00
Entity Address
523 N 3RD ST
BRAINERD, MN 56401
Medicare Provider Number
240075
Participating Start Date
4/1/2018
Last Recertification Date
8/19/2024
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
7/11/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Pilot, CFO
(218) 828-7642
Contract Pharmacy Representative
Essentia Health
Kenzie Hohman, Senior Director of Ambulatory Pharmacy
(715) 817-7171
Signed By Date
7/11/2019
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