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THRIFTY WHITE PHARMACY #791
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
THRIFTY WHITE PHARMACY #791
Pharmacy Address
111 N MAIN AVE
PO BOX 460
BAUDETTE, MN 56623-2466
Pharmacy Comments
Contract Details
Approval Date
1/7/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lisa Sue Miller, Chief Financial Officer
(218) 333-5523
Contract Pharmacy Representative
Thrifty White
Zach Winter, Corporate Manager
(763) 248-7554
Signed By Date
1/7/2020
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