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YE OLDE MEDICINE SHOPPE
CAH351319-00 Pembina County Memorial Hospital Assoc
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Covered Entity Details
Entity Name
Pembina County Memorial Hospital Assoc
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH351319-00
Entity Address
301 Mountain Street
Cavalier, ND 58220
Medicare Provider Number
351319
Participating Start Date
1/1/2014
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
YE OLDE MEDICINE SHOPPE
Pharmacy Address
LAURELYN W LARSON R PH
503 PARK ST W
PARK RIVER, ND 58270
Pharmacy Comments
Contract Details
Approval Date
12/6/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tanya Sharp, CEO
(701) 265-6336
Contract Pharmacy Representative
Laurie Larson, President, R.Ph.
(701) 284-7676
Signed By Date
11/13/2013
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