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KILLDEER PHARMACY
CH081150L 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 - Beulah Middle School Clinic
Type
HRSA-Funded Health Center
340B ID
CH081150L
Entity Address
1700 Central Ave N
Beulah, ND 58523-6004
Grant Number
H80CS09469
Participating Start Date
7/1/2023
Last Recertification Date
2/9/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
KILLDEER PHARMACY
Pharmacy Address
JODY DOE/OWNER
220 4TH AVE SW STE B
PO BOX 745
KILLDEER, ND 58640
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
KILLDEER PHARMACY
Jody Doe, President
(701) 764-5093
Signed By Date
10/13/2023
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