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ST JOSEPH'S MCAULEY PHARMACY
CAH241301-00 LAKEWOOD HEALTH CENTER
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Covered Entity Details
Entity Name
LAKEWOOD HEALTH CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241301-00
Entity Address
600 MAIN AVENUE S
BAUDETTE, MN 56623
Medicare Provider Number
241301
Participating Start Date
4/1/2019
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
ST JOSEPH'S MCAULEY PHARMACY
Pharmacy Address
DIGNITY HEALTH
500 W THOMAS RD, STE 190
PHOENIX, AZ 85013-4237
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/30/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffry Alan Stampohar, VP
(218) 634-3401
Contract Pharmacy Representative
St. Joseph's Hospital and Medical Center
Greg Blank, Director of Pharmacy
(602) 406-4744
Signed By Date
7/14/2020
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