Contract Pharmacy Details

ESSENTIA HEALTH BRAINERD PHARMACY
DSH240101 ST MARYS REGIONAL HEALTH CENTER

Covered Entity Details

Entity Name

ST MARYS REGIONAL HEALTH CENTER

Subdivision Name

Essentia Health St. Mary's

Type

Disproportionate Share Hospital

340B ID

DSH240101

Entity Address

1027 WASHINGTON AVE
DETROIT LAKES, MN 56501

Medicare Provider Number

240101

Participating Start Date

1/1/2015

Last Recertification Date

8/27/2024

Pharmacy Details

Pharmacy Name

ESSENTIA HEALTH BRAINERD PHARMACY

Pharmacy Address

2024 S 6TH ST
BRAINERD, MN 56401-4529

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

Tanner Goodrich, Senior Vice President of Operations
(218) 847-0851

Contract Pharmacy Representative

Essentia Health
Kenzie Hohman, Senior Director of Ambulatory Pharmacy
(715) 817-7171

Signed By Date

4/15/2024

340B Drug Pricing Program Database