Contract Pharmacy Details

WHITE DRUG #66
CAH351322-01 ASHLEY MEDICAL CENTER

Covered Entity Details

Entity Name

ASHLEY MEDICAL CENTER

Subdivision Name

ASHLEY MEDICAL CENTER / Ashley Medical Center AMC Ashley Clinic

Type

Critical Access Hospital

340B ID

CAH351322-01

Entity Address

612 CENTER AVE N
AMC CLINIC
ASHLEY, ND 58413-7013

Medicare Provider Number

351322

Outpatient Facility Provider Number

353423

Participating Start Date

10/1/2015

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

WHITE DRUG #66

Pharmacy Address

109 W MAIN ST
P.O. BOX 329
ASHLEY, ND 58413-7003

Pharmacy Comments

Contract Details

Approval Date

10/15/2015

Contract Begin Date

1/1/2016

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Jerry Lepp, CFO
(701) 288-3433 Ext: 264

Contract Pharmacy Representative

Alicia Hager, Pharmacy Operation Specialist
(763) 463-4482

Signed By Date

10/15/2015

340B Drug Pricing Program Database