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PRAIRIE PHARMACY FA1
RRC350070-00 INNOVIS HEALTH
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Covered Entity Details
Entity Name
INNOVIS HEALTH
Subdivision Name
Type
Rural Referral Center
340B ID
RRC350070-00
Entity Address
3000 32ND AVENUE S
FARGO, ND 58103
Medicare Provider Number
350070
Participating Start Date
4/1/2022
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
PRAIRIE PHARMACY FA1
Pharmacy Address
NORTH PRAIRIE PHARMACIES LLC
4731 13TH AVE S
FARGO, ND 58103
Pharmacy Comments
Contract Details
Approval Date
5/1/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Al Hurley, COO
(701) 364-7667
Contract Pharmacy Representative
Prairie Pharmacy
Leslie Satterlund, Pharmacist In Charge
(701) 373-0235
Signed By Date
5/1/2023
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