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ESSENTIA HEALTH SUPERIOR BELKNAP PHARMAC
CAH241350-00 ESSENTIA HEALTH MOOSE LAKE
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Covered Entity Details
Entity Name
ESSENTIA HEALTH MOOSE LAKE
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241350-00
Entity Address
4572 COUNTY ROAD 61
MOOSE LAKE, MN 55767
Medicare Provider Number
241350
Participating Start Date
8/19/2010
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
ESSENTIA HEALTH SUPERIOR BELKNAP PHARMAC
Pharmacy Address
204 BELKNAP ST STE 100
SUPERIOR, WI 54880-2905
Pharmacy Comments
Contract Details
Approval Date
4/15/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bradley Beard, Chief Operating Officer
(218) 786-2652
Contract Pharmacy Representative
Essentia Health
Kenzie Hohman, Senior Director of Ambulatory Pharmacy
(715) 817-7171
Signed By Date
4/15/2024
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