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HEALTHY PHARMACY CO.
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
HEALTHY PHARMACY CO.
Pharmacy Address
DBA KITTSON PHARMACY
1010 S BIRCH AVE
HALLOCK, MN 56728
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
1/17/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Everett Butler, CEO
(218) 843-3803
Contract Pharmacy Representative
Kittson Pharmacy
Loften Deprez, Owner
(919) 636-0021
Signed By Date
1/17/2023
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