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IVERSON CORNER DRUG
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
IVERSON CORNER DRUG
Pharmacy Address
408 MINNESOTA AVE NW
BEMIDJI, MN 56601-5660
Pharmacy Comments
Contract Details
Approval Date
10/7/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joy Ellen Johnson, Vice President of Operations
(218) 333-6422
Contract Pharmacy Representative
Iverson Corner Drug
Ryan Okerlund, President
(218) 444-3000
Signed By Date
10/7/2019
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