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ESSENTIA HEALTH DETROIT LAKES PHARMACY
RRC240002-00 ST. MARYS MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. MARYS MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC240002-00
Entity Address
402 E 2ND STREET
DULUTH, MN 55805
Medicare Provider Number
240002
Participating Start Date
10/1/2024
Last Recertification Date
Pharmacy Details
Pharmacy Name
ESSENTIA HEALTH DETROIT LAKES PHARMACY
Pharmacy Address
211 FRAZEE ST E
DETROIT LAKES, MN 56501-3503
Pharmacy Comments
Contract Details
Approval Date
7/31/2024
Contract Begin Date
10/1/2024
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
7/2/2024
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