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ESSENTIA HEALTH LAKEWALK 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 LAKEWALK PHARMACY
Pharmacy Address
1502 LONDON RD STE 101
DULUTH, MN 55812-1787
Pharmacy Comments
Contract Details
Approval Date
1/10/2017
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
Scott Nigon, CFO
(218) 786-3212
Contract Pharmacy Representative
Essentia Health
Tim Cernohous, Director of Ambulatory Pharmacy
(218) 786-8516
Signed By Date
1/10/2017
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