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ESSENTIA HEALTH BAXTER PHARMACY
DSH240075 ST. JOSEPHS MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. JOSEPHS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240075
Entity Address
523 NORTH THIRD STREET
BRAINERD, MN 56401
Medicare Provider Number
240075
Participating Start Date
1/1/2016
Last Recertification Date
9/1/2016
Entity Termination Date
1/1/2018
Pharmacy Details
Pharmacy Name
ESSENTIA HEALTH BAXTER PHARMACY
Pharmacy Address
13060 ISLE DR
BAXTER, MN 56425
Pharmacy Comments
Contract Details
Approval Date
12/8/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
David Pilot, CFO
(218) 828-7642
Contract Pharmacy Representative
Essentia Health
Tim Cernohous, Director of Ambulatory Pharmacy
(218) 786-8516
Signed By Date
12/8/2015
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