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WHITE DRUG #52
CAH161302-00 IOWA SPECIALTY HOSPITAL - CLARION
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Covered Entity Details
Entity Name
IOWA SPECIALTY HOSPITAL - CLARION
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161302-00
Entity Address
1316 S Main St
CLARION, IA 50525
Medicare Provider Number
161302
Participating Start Date
9/14/2010
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WHITE DRUG #52
Pharmacy Address
706 38TH ST N STE B
FARGO, ND 58102-2953
Pharmacy Comments
Contract Details
Approval Date
1/14/2022
Contract Begin Date
2/14/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/28/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
GREG POLZIN, CFO
(641) 444-5623
Contract Pharmacy Representative
Thrifty Drug Stores, Inc.
Anne Brader, CFO
(763) 513-4331
Signed By Date
1/14/2022
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