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ESSENTIA HEALTH DULUTH 3RD STREET PHARMA
CAH521329-00 ST MARYS HOSPITAL OF SUPERIOR
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Covered Entity Details
Entity Name
ST MARYS HOSPITAL OF SUPERIOR
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521329-00
Entity Address
3500 TOWER AVE
SUPERIOR, WI 54880
Medicare Provider Number
521329
Participating Start Date
9/30/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
ESSENTIA HEALTH DULUTH 3RD STREET PHARMA
Pharmacy Address
400 E 3RD ST STE A
DULUTH, MN 55805-1951
Pharmacy Comments
06/15/2012 change pharmacy name (was DULUTH CLINIC PHARMACY)
Contract Details
Approval Date
7/11/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Terry Jacobson, Administrator
(715) 817-7014
Contract Pharmacy Representative
Essentia Health
Kenzie Hohman, Senior Director of Ambulatory Pharmacy
(715) 817-7171
Signed By Date
7/11/2014
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