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WHITE DRUG #52
CAH161369-00 CRAWFORD COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CRAWFORD COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161369-00
Entity Address
100 MEDICAL PARKWAY
DENISON, IA 51442-2210
Medicare Provider Number
161369
Participating Start Date
4/1/2011
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WHITE DRUG #52
Pharmacy Address
706 38TH ST N STE B
FARGO, ND 58102-2953
Pharmacy Comments
Contract Details
Approval Date
3/7/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/27/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
NANCY J. CARLSON, CHIEF FINANCIAL OFFICER
(712) 265-2505
Contract Pharmacy Representative
Thrifty White
Timothy Weippert, EVP of Pharmacy
(763) 513-4365
Signed By Date
1/15/2013
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