Contract Pharmacy Details

ESSENTIA HEALTH BRAINERD PHARMACY
DSH240075 ST. JOSEPHS MEDICAL CENTER

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 BRAINERD PHARMACY

Pharmacy Address

2024 S 6TH ST
BRAINERD, MN 56401-4529

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

340B Drug Pricing Program Database