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COBORN'S PHARMACY #16
CAH241376-00 GLACIAL RIDGE HEALTH SYSTEM
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Covered Entity Details
Entity Name
GLACIAL RIDGE HEALTH SYSTEM
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241376-00
Entity Address
10 FOURTH AVE SE
GLENWOOD, MN 56334
Medicare Provider Number
241376
Participating Start Date
10/1/2011
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
COBORN'S PHARMACY #16
Pharmacy Address
645 LAKE ST. S.
LONG PRAIRIE, MN 56347
Pharmacy Comments
Contract Details
Approval Date
1/7/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KYLE CHASE, CFO
(320) 634-2206
Contract Pharmacy Representative
Coborn's Pharmacy
Rebecca Pickler, District Pharmacy Manager
(320) 534-2745
Signed By Date
1/7/2025
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