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COUNTRY DRUG STORE
CAH351314-00 JACOBSON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JACOBSON MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH351314-00
Entity Address
601 EAST STREET NORTH
ELGIN, ND 58533
Medicare Provider Number
351314
Participating Start Date
7/1/2015
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
COUNTRY DRUG STORE
Pharmacy Address
116 NORTH AVE E
RICHARDTON, ND 58652-7044
Pharmacy Comments
Contract Details
Approval Date
7/12/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Theo Allen Stoller, CEO
(701) 584-7233
Contract Pharmacy Representative
COUNTRY DRUG STORE
DOREEN STUDSRUD, PRESIDENT
(701) 974-3558
Signed By Date
7/12/2022
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