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THRIFTY WHITE PHARMACY #771
CAH241350-00 ESSENTIA HEALTH MOOSE LAKE
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Covered Entity Details
Entity Name
ESSENTIA HEALTH MOOSE LAKE
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241350-00
Entity Address
4572 COUNTY ROAD 61
MOOSE LAKE, MN 55767
Medicare Provider Number
241350
Participating Start Date
8/19/2010
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE PHARMACY #771
Pharmacy Address
4570 COUNTY HIGHWAY 61
MOOSE LAKE, MN 55767
Pharmacy Comments
Contract Details
Approval Date
1/12/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/13/2017
Agreement registered in error
Contacts
Covered Entity Signing Official
Michael J. Delfs, CEO
(218) 485-5858
Contract Pharmacy Representative
KENDRA METZ, PHARMACY MGR
(218) 485-2111
Signed By Date
1/12/2017
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