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ESSENTIA HEALTH LAKEWALK PHARMACY
CAH241357-00 FIRST CARE MEDICAL SERVICES
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Covered Entity Details
Entity Name
FIRST CARE MEDICAL SERVICES
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241357-00
Entity Address
900 HILLIGOSS BLVD SE
FOSSTON, MN 56542
Medicare Provider Number
241357
Participating Start Date
4/1/2011
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
ESSENTIA HEALTH LAKEWALK PHARMACY
Pharmacy Address
1502 LONDON RD STE 101
DULUTH, MN 55812-1787
Pharmacy Comments
Contract Details
Approval Date
1/23/2017
Contract Begin Date
4/1/2017
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
Kimberly Bodensteiner, CFO
(218) 435-7633
Contract Pharmacy Representative
Essentia Health
Tim Cernohous, Director of Ambulatory Pharmacy
(218) 786-8516
Signed By Date
1/23/2017
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