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MEDICAL PHARMACY SOUTH
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
MEDICAL PHARMACY SOUTH
Pharmacy Address
4151 45TH ST S
FARGO, ND 58104-4312
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
Medical Pharmacy South
Lana Kirschemann, Pharmacy Manager
(701) 282-8075
Signed By Date
5/1/2023
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