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PARK NICOLLET PHARMACY
CAH521308-00 AMERY REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
AMERY REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521308-00
Entity Address
265 E GRIFFIN ST
AMERY, WI 54001
Medicare Provider Number
521308
Participating Start Date
9/20/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
PARK NICOLLET PHARMACY
Pharmacy Address
3850 PARK NICOLLET BLVD.
ST LOUIS PARK, MN 55416
Pharmacy Comments
Contract Details
Approval Date
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Doug Edward Johnson, VP/CFO
(715) 243-2852
Contract Pharmacy Representative
Westfields Hospital & Clinic
Doug Edward Johnson, VP/CFO
(715) 243-2852
Signed By Date
1/14/2020
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