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THRIFTY WHITE PHARMACY #788
SCH240064-00 GRAND ITASCA CLINIC AND HOSPITAL
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Covered Entity Details
Entity Name
GRAND ITASCA CLINIC AND HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH240064-00
Entity Address
1601 GOLF COURSE ROAD
GRAND RAPIDS, MN 55744
Medicare Provider Number
240064
Participating Start Date
7/1/2011
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
THRIFTY WHITE PHARMACY #788
Pharmacy Address
2410 S. POKEGAMA AVE
GRAND RAPIDS, MN 55744
Pharmacy Comments
Contract Details
Approval Date
4/11/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mike Youso, CEO
(218) 999-1449
Contract Pharmacy Representative
Grand Itasca Clinic & Hospital
MELISSA WALTERS, DIRECTOR OF PHARMACY
(218) 999-1875
Signed By Date
4/11/2018
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