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THRIFTY WHITE DRUG #760
CAH241343-00 AVERA GRANITE FALLS
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Covered Entity Details
Entity Name
AVERA GRANITE FALLS
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241343-00
Entity Address
345 10TH AVE
GRANITE FALLS, MN 56241
Medicare Provider Number
241343
Participating Start Date
9/29/2010
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE DRUG #760
Pharmacy Address
760 PRENTICE ST
GRANITE FALLS, MN 56241
Pharmacy Comments
Contract Details
Approval Date
7/13/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tom Kooiman, ADMINISTRATOR/CEO
(320) 564-6201
Contract Pharmacy Representative
Thrifty White
Timothy Weippert, EVP of Pharmacy
(763) 513-4365
Signed By Date
7/13/2017
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