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KITTSON PHARMACY
CAH241336-01 KITTSON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
KITTSON MEMORIAL HOSPITAL
Subdivision Name
KITTSON MEMORIAL CLINIC - KARLSTAD - Kittson Memorial Clinic - Karlstad
Type
Critical Access Hospital
340B ID
CAH241336-01
Entity Address
205 Roosevelt Ave
Karlstad, MN 56732
Medicare Provider Number
241336
Outpatient Facility Provider Number
243427
Participating Start Date
10/1/2019
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
KITTSON PHARMACY
Pharmacy Address
1010 S BIRCH AVE
HALLOCK, MN 56728
Pharmacy Comments
Contract Details
Approval Date
10/14/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2023
OPA Terminated due to audit finding
Contacts
Covered Entity Signing Official
Brenda Parnell, CFO
(907) 229-3546
Contract Pharmacy Representative
Kittson Pharmacy
Loften Deprez, Owner
(919) 636-0021
Signed By Date
10/14/2022
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