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GRAND ST. PAUL CVS, L.L.C.
SCH240075-00 ST JOSEPHS MEDICAL CENTER
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Covered Entity Details
Entity Name
ST JOSEPHS MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH240075-00
Entity Address
523 N 3RD ST
BRAINERD, MN 56401
Medicare Provider Number
240075
Participating Start Date
4/1/2018
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
GRAND ST. PAUL CVS, L.L.C.
Pharmacy Address
CVS PHARMACY # 16186
14546 DELLWOOD DRIVE
BAXTER, MN 56425
Pharmacy Comments
Contract Details
Approval Date
1/19/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael J Larson, Vice President of Operations
(218) 828-7656
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/19/2023
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