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WHITE DRUG #72
CAH351311-00 LISBON AREA HEALTH SERVICES
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Covered Entity Details
Entity Name
LISBON AREA HEALTH SERVICES
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH351311-00
Entity Address
905 MAIN ST
LISBON, ND 58054
Medicare Provider Number
351311
Participating Start Date
9/28/2010
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WHITE DRUG #72
Pharmacy Address
404 MAIN ST
P.O. BOX 770
LISBON, ND 58054-4142
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Keith Heuser, President
(701) 845-6400
Contract Pharmacy Representative
Thrifty White
Zach Winter, Corporate Manager
(763) 248-7554
Signed By Date
1/15/2020
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