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KITTSON PHARMACY
CAH241336-00 KITTSON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
KITTSON MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241336-00
Entity Address
1010 S BIRCH AVE
HALLOCK, MN 56728
Medicare Provider Number
241336
Participating Start Date
4/1/2017
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
1/17/2023
Ownership change
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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