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SEIP DRUG #10
CAH241329-00 LAKEWOOD HEALTH SYSTEM
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Covered Entity Details
Entity Name
LAKEWOOD HEALTH SYSTEM
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241329-00
Entity Address
49725 COUNTY 83
STAPLES, MN 56479
Medicare Provider Number
241329
Participating Start Date
9/24/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SEIP DRUG #10
Pharmacy Address
124 2ND AVE NW
BERTHA, MN 56437-0157
Pharmacy Comments
Contract Details
Approval Date
3/13/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/15/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Katie Polman, Project Manager
(218) 894-8521
Contract Pharmacy Representative
Seip Drug
Nate Seip, CEO
(218) 385-3360
Signed By Date
1/15/2013
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