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CROSSLAKE DRUG
SCH240075-50 ST JOSEPHS MEDICAL CENTER
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Covered Entity Details
Entity Name
ST JOSEPHS MEDICAL CENTER
Subdivision Name
Essentia Health St. Joseph's - Baxter Clinic / Primary Care Psych
Type
Sole Community Hospital
340B ID
SCH240075-50
Entity Address
13060 ISLE DRIVE
BAXTER, MN 56425
Medicare Provider Number
240075
Outpatient Facility Provider Number
Participating Start Date
4/1/2020
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
CROSSLAKE DRUG
Pharmacy Address
14311 GOULD ST
PO BOX 578
CROSSLAKE, MN 56442-5501
Pharmacy Comments
Contract Details
Approval Date
4/20/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/2/2023
Agreement registered in error
Contacts
Covered Entity Signing Official
Michael J Larson, Vice President of Operations
(218) 828-7656
Contract Pharmacy Representative
Crosslake Drug
Steve Kappes, Owner
(218) 692-2502
Signed By Date
4/20/2023
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