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SHOPKO PHARMACY #2742
SCH350019-00 ALTRU HOSPITAL
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Covered Entity Details
Entity Name
ALTRU HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH350019-00
Entity Address
1200 SOUTH COLUMBIA ROAD
GRAND FORKS, ND 58201
Medicare Provider Number
350019
Participating Start Date
8/5/2010
Last Recertification Date
9/11/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2742
Pharmacy Address
421 GATEWAY DR NE
EAST GRAND FORKS, MN 56721
Pharmacy Comments
Contract Details
Approval Date
4/12/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/20/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
DWIGHT William THOMPSON, CFO
(701) 780-5211
Contract Pharmacy Representative
Shopko Pharmacy
Debi Danbury, 340B Program Manager
(920) 429-7613
Signed By Date
4/12/2018
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