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HAZEN HEALTH PHARMACY
CH081150N Coal Country Community Health Center
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Covered Entity Details
Entity Name
Coal Country Community Health Center
Subdivision Name
Coal Country Community Health Center - Killdeer High School Clinic
Type
HRSA-Funded Health Center
340B ID
CH081150N
Entity Address
1415 High St NW
Killdeer, ND 58640
Grant Number
H80CS09469
Participating Start Date
10/1/2023
Last Recertification Date
2/9/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
HAZEN HEALTH PHARMACY
Pharmacy Address
30 MAIN ST W
HAZEN, ND 58545
Pharmacy Comments
Contract Details
Approval Date
10/13/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Darrold Bertsch, Interim CEO
(701) 873-7484
Contract Pharmacy Representative
Hazen Health Pharmacy
Wyatt Martenson, PharmD
(701) 748-2312
Signed By Date
10/13/2023
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