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COBORN'S PHARMACY
DSH240036 ST. CLOUD HOSPITAL
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Covered Entity Details
Entity Name
ST. CLOUD HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240036
Entity Address
1406 6TH AVENUE NORTH
Saint Cloud, MN 56303
Medicare Provider Number
240036
Participating Start Date
7/1/2016
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
COBORN'S PHARMACY
Pharmacy Address
COBORN'S PHARMACY #2001
110 1ST ST S
SAUK RAPIDS, MN 56379-1453
Pharmacy Comments
Contract Details
Approval Date
5/13/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/9/2016
Agreement registered in error
Contacts
Covered Entity Signing Official
Greg Klugherz, CFO
(320) 255-5655
Contract Pharmacy Representative
Coborn's
Jim Cox, 340B Program Director
(320) 257-5505
Signed By Date
5/13/2016
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