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THRIFTY WHITE PHARMACY #038
DSH240084 ESSENTIA HEALTH VIRGINIA
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Covered Entity Details
Entity Name
ESSENTIA HEALTH VIRGINIA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240084
Entity Address
901 9TH STREET NORTH
VIRGINIA, MN 55792-2398
Medicare Provider Number
240084
Participating Start Date
1/1/2021
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE PHARMACY #038
Pharmacy Address
202 S 2ND AVE
VIRGINIA, MN 55792-2614
Pharmacy Comments
Contract Details
Approval Date
11/16/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/23/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sam Stone, COO
(218) 742-8600 Ext: 2496
Contract Pharmacy Representative
Thrifty White
Zach Winter, Corporate Manager
(763) 248-7554
Signed By Date
10/15/2020
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