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SAMUELSON'S DRUG STORE
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
SAMUELSON'S DRUG STORE
Pharmacy Address
118 W 5TH ST
STARBUCK, MN 56381-2426
Pharmacy Comments
Contract Details
Approval Date
7/6/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
KYLE CHASE, CFO
(320) 634-2206
Contract Pharmacy Representative
Samuelson's Drug
Donald Samuelson, Pharmacist & Owner
(320) 239-2246
Signed By Date
7/6/2013
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