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CENTRACARE PHARMACY HEALTH
SCH240036-00 St. Cloud Hospital
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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 HEALTH
Pharmacy Address
PLAZA
1900 CENTRACARE CIR
SUITE 1350
SAINT CLOUD, MN 56303-5000
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
7/1/2016
Covered Entity Terminated
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
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