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THRIFTY WHITE PHARMACY #728
SCH240064-00 GRAND ITASCA CLINIC AND HOSPITAL
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Covered Entity Details
Entity Name
GRAND ITASCA CLINIC AND HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH240064-00
Entity Address
1601 GOLF COURSE ROAD
GRAND RAPIDS, MN 55744
Medicare Provider Number
240064
Participating Start Date
7/1/2011
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE PHARMACY #728
Pharmacy Address
1105 S POKEGAMA AVE
GRAND RAPIDS, MN 55744
Pharmacy Comments
Contract Details
Approval Date
1/15/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sarah Gustafson, VP of Finance
(218) 999-1702
Contract Pharmacy Representative
Thrifty White
Timothy Weippert, EVP of Pharmacy
(763) 513-4365
Signed By Date
1/15/2014
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