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GREENBUSH PHARMACY
CAH241381-00 SANFORD THIEF RIVER FALLS
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Covered Entity Details
Entity Name
SANFORD THIEF RIVER FALLS
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241381-00
Entity Address
3001 SANFORD PARKWAY
THIEF RIVER FALLS, MN 56701-2819
Medicare Provider Number
241381
Participating Start Date
4/1/2011
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
GREENBUSH PHARMACY
Pharmacy Address
152 MAIN ST N
P O BOX 39
GREENBUSH, MN 56726-4015
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tiffany Lawrence, President and CEO, Fargo
(701) 417-2314
Contract Pharmacy Representative
Mattson Pharmacy Incorporated
Dean Mattson, Pharmacy Owner
(218) 343-1856
Signed By Date
7/15/2020
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