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ESSENTIA HEALTH SUPERIOR EAST PHARMACY
CH0510280 LAKE SUPERIOR COMMUNITY HEALTH CENTER
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Covered Entity Details
Entity Name
LAKE SUPERIOR COMMUNITY HEALTH CENTER
Subdivision Name
LAKE SUPERIOR HEALTH CENTER
Type
HRSA-Funded Health Center
340B ID
CH0510280
Entity Address
4325 Grand Ave
Duluth, MN 55807-2730
Grant Number
H80CS00811
Participating Start Date
10/1/2000
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
ESSENTIA HEALTH SUPERIOR EAST PHARMACY
Pharmacy Address
2202 E 2ND ST STE 477
SUPERIOR, WI 54880-3779
Pharmacy Comments
Contract Details
Approval Date
1/13/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jessie Peterson, Chief Executive Officer
(218) 336-3503
Contract Pharmacy Representative
Essentia Health
Kenzie Hohman, Senior Director of Ambulatory Pharmacy
(715) 817-7171
Signed By Date
1/13/2022
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