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THRIFTY WHITE PHARMACY #034
CAH351336-00 ST JOSEPHS HOSPITAL & HEALTH CTR
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Covered Entity Details
Entity Name
ST JOSEPHS HOSPITAL & HEALTH CTR
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH351336-00
Entity Address
2500 Fairway St
DICKINSON, ND 58601
Medicare Provider Number
351336
Participating Start Date
1/1/2016
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE PHARMACY #034
Pharmacy Address
2265 3RD AVE W
DICKINSON, ND 58601-2605
Pharmacy Comments
Contract Details
Approval Date
12/18/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/14/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Reed E. Reyman, MBO President
(701) 456-4271
Contract Pharmacy Representative
Ray Traut, Pharmacist (Pharmacy Manager)
(701) 225-2121
Signed By Date
12/18/2015
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