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ESSENTIA HEALTH SUPERIOR PHARMACY
CAH241321-00 GRACEVILLE HEALTH CENTER
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Covered Entity Details
Entity Name
GRACEVILLE HEALTH CENTER
Subdivision Name
ESSENTIA HEALTH HOLY TRINITY HOSPITAL
Type
Critical Access Hospital
340B ID
CAH241321-00
Entity Address
115 W 2ND ST
GRACEVILLE, MN 56240
Medicare Provider Number
241321
Participating Start Date
9/16/2010
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
ESSENTIA HEALTH SUPERIOR PHARMACY
Pharmacy Address
3500 TOWER AVE STE A
SUPERIOR, WI 54880
Pharmacy Comments
Contract Details
Approval Date
10/13/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/7/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Julie Rosenberg, Administrator
(320) 748-8203
Contract Pharmacy Representative
Essentia Health
Tim Cernohous, Director of Ambulatory Pharmacy
(218) 786-8516
Signed By Date
10/13/2016
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