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WHITE DRUG #61
CAH241325-00 CCM Health
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Covered Entity Details
Entity Name
CCM Health
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241325-00
Entity Address
824 N 11Th St
Montevideo, MN 56265
Medicare Provider Number
241325
Participating Start Date
1/1/2012
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WHITE DRUG #61
Pharmacy Address
706 38TH ST NW UNIT A
FARGO, ND 58102
Pharmacy Comments
Contract Details
Approval Date
1/13/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mark E. Paulson, Administrator
(320) 321-8100
Contract Pharmacy Representative
Thrifty White
Timothy Weippert, EVP of Pharmacy
(763) 513-4365
Signed By Date
1/13/2014
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