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ESSENTIA HEALTH GRAND RAPIDS PHARMACY
DSH240084 ESSENTIA HEALTH VIRGINIA
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Covered Entity Details
Entity Name
ESSENTIA HEALTH VIRGINIA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240084
Entity Address
901 9TH STREET NORTH
VIRGINIA, MN 55792-2398
Medicare Provider Number
240084
Participating Start Date
1/1/2021
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
ESSENTIA HEALTH GRAND RAPIDS PHARMACY
Pharmacy Address
RETAIL PHARMACY - COLLECTOR
1542 GOLF COURSE RD STE 205
GRAND RAPIDS, MN 55744
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
Sam Stone, COO
(218) 742-8600 Ext: 2496
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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