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NORTHERN MONTANA PHARMACY
DSH270032 NORTHERN MONTANA HOSPITAL
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Covered Entity Details
Entity Name
NORTHERN MONTANA HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH270032
Entity Address
30-13TH STREET
HAVRE, MT 59501
Medicare Provider Number
270032
Participating Start Date
10/1/2009
Last Recertification Date
9/5/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
NORTHERN MONTANA PHARMACY
Pharmacy Address
CALVIN LIEN (PIC.)
20 13TH ST W
PO BOX 1231
HAVRE, MT 59501-5215
Pharmacy Comments
Contract Details
Approval Date
10/1/2009
Contract Begin Date
10/1/2009
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/29/2020
CE terminated due to audit finding
Contacts
Covered Entity Signing Official
DAVID C. HENRY, PRESIDENT/CEO
(406) 262-1302
Contract Pharmacy Representative
NMHC
DAVID C. HENRY, PRESIDENT/CEO
(406) 262-1302
Signed By Date
9/16/2009
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