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THRIFTY WHITE PHARMACY #735
CAH241379-00 Prairie Ridge Hospital and Health Services
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Covered Entity Details
Entity Name
Prairie Ridge Hospital and Health Services
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241379-00
Entity Address
1411 Hwy 79 East
Elbow Lake, MN 56531
Medicare Provider Number
241379
Participating Start Date
1/1/2014
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE PHARMACY #735
Pharmacy Address
111 W VERNON AVE
FERGUS FALLS, MN 56537-2718
Pharmacy Comments
Contract Details
Approval Date
4/13/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Renae L Lien, Pharmacy Director
(218) 685-7376
Contract Pharmacy Representative
Prairie Ridge Hospital & Health Services
Renae L Lien, Pharmacy Director
(218) 685-7376
Signed By Date
4/13/2015
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