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COBORN'S PHARMACY #27
CAH241355-00 GLENCOE REGIONAL HEALTH SERVICES
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Covered Entity Details
Entity Name
GLENCOE REGIONAL HEALTH SERVICES
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241355-00
Entity Address
1805 HENNEPIN AVENUE NORTH
GLENCOE, MN 55336
Medicare Provider Number
241355
Participating Start Date
4/1/2011
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
COBORN'S PHARMACY #27
Pharmacy Address
2211 11TH ST E
GLENCOE, MN 55336-2629
Pharmacy Comments
Contract Details
Approval Date
12/12/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/19/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JON D. BRABAND, PRESIDENT
(320) 864-7752
Contract Pharmacy Representative
Coborn's
Jim Cox, 340B Program Director
(320) 257-5505
Signed By Date
10/15/2012
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