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GRAND ST. PAUL CVS, L.L.C.
DSH240101 ST MARYS REGIONAL HEALTH CENTER
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Covered Entity Details
Entity Name
ST MARYS REGIONAL HEALTH CENTER
Subdivision Name
Essentia Health St. Mary's
Type
Disproportionate Share Hospital
340B ID
DSH240101
Entity Address
1027 WASHINGTON AVE
DETROIT LAKES, MN 56501
Medicare Provider Number
240101
Participating Start Date
1/1/2015
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
GRAND ST. PAUL CVS, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 5616
329 FRAZEE STREET EAST
DETROIT LAKES, MN 56501
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
Tanner Goodrich, Senior Vice President of Operations
(218) 847-0851
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/19/2023
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