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JACOBSON MEMORIAL HOSPITAL CARE CENTER
CAH351314-00 JACOBSON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JACOBSON MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH351314-00
Entity Address
601 EAST STREET NORTH
ELGIN, ND 58533
Medicare Provider Number
351314
Participating Start Date
7/1/2015
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
JACOBSON MEMORIAL HOSPITAL CARE CENTER
Pharmacy Address
601 EAST ST N
PO BOX 367
ELGIN, ND 58533
Pharmacy Comments
Contract Details
Approval Date
6/25/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/13/2021
Agreement registered in error
Contacts
Covered Entity Signing Official
Theo Stoller, CEO
(701) 584-7233
Contract Pharmacy Representative
Chuck Oien, Pharmacist
(701) 584-7233
Signed By Date
6/25/2015
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