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ESSENTIA HEALTH SPECIALTY PHARMACY
CAH241309-00 PINE MEDICAL CENTER
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Covered Entity Details
Entity Name
PINE MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241309-00
Entity Address
705 LUNDORFF DR
SANDSTONE, MN 55072
Medicare Provider Number
241309
Participating Start Date
7/1/2011
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
ESSENTIA HEALTH SPECIALTY PHARMACY
Pharmacy Address
204 BELKNAP ST STE 200
SUPERIOR, WI 54880-2905
Pharmacy Comments
Contract Details
Approval Date
10/13/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Scott Nigon, CFO
(218) 786-3212
Contract Pharmacy Representative
Essentia Health
Kenzie Hohman, Senior Director of Ambulatory Pharmacy
(715) 817-7171
Signed By Date
10/13/2015
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