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ESSENTIA HEALTH STAPLES PHARMACY
DSH240101 ST MARYS REGIONAL HEALTH CENTER
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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 STAPLES PHARMACY
Pharmacy Address
301 2ND AVE NW STE 1010
STAPLES, MN 56479
Pharmacy Comments
Contract Details
Approval Date
10/15/2024
Contract Begin Date
1/1/2025
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
10/15/2024
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