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ESSENTIA HEALTH PINE RIVER PHARMACY
RRC350070-00 INNOVIS HEALTH
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Covered Entity Details
Entity Name
INNOVIS HEALTH
Subdivision Name
Type
Rural Referral Center
340B ID
RRC350070-00
Entity Address
3000 32ND AVENUE S
FARGO, ND 58103
Medicare Provider Number
350070
Participating Start Date
4/1/2022
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
ESSENTIA HEALTH PINE RIVER PHARMACY
Pharmacy Address
280 BARCLAY AVE STE 1100
PINE RIVER, MN 56474
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
Al Hurley, COO
(701) 364-7667
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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