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WHITE DRUG #52
CAH241336-00 KITTSON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
KITTSON MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241336-00
Entity Address
1010 S BIRCH AVE
HALLOCK, MN 56728
Medicare Provider Number
241336
Participating Start Date
4/1/2017
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WHITE DRUG #52
Pharmacy Address
706 38TH ST N STE B
FARGO, ND 58102-2953
Pharmacy Comments
Contract Details
Approval Date
7/11/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/28/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Jeni Schwenzfeier, Chief Financial Officer
(218) 843-3612
Contract Pharmacy Representative
Thrifty White
Zach Winter, Corporate Manager
(763) 248-7554
Signed By Date
7/11/2019
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