Contract Pharmacy Details

CENTRACARE PHARMACY NORTHWAY
SCH240036-00 St. Cloud Hospital

Covered Entity Details

Entity Name

St. Cloud Hospital

Subdivision Name

Type

Sole Community Hospital

340B ID

SCH240036-00

Entity Address

1406 Sixth Avenue North
Saint Cloud, MN 56303-1901

Medicare Provider Number

240036

Participating Start Date

4/1/2012

Last Recertification Date

8/5/2015

Entity Termination Date

7/1/2016

Pharmacy Details

Pharmacy Name

CENTRACARE PHARMACY NORTHWAY

Pharmacy Address

1555 NORTHWAY DR STE 150
SAINT CLOUD, MN 56303-4912

Pharmacy Comments

Contract Details

Approval Date

9/10/2012

Contract Begin Date

9/10/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/31/2015
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Craig Broman, President, Saint Cloud Hospital
(320) 656-7000

Contract Pharmacy Representative

CentraCare
Keith Karsky, Coordinator, Retail Pharmacy Services
(320) 229-5199 Ext: 70580

Signed By Date

8/29/2012

340B Drug Pricing Program Database