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PED243302-68 Children’s Health Care d/b/a Children’s Minnesota (Terminated)
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Main Details
Name
Children’s Health Care d/b/a Children’s Minnesota
Subdivision Name
Maple Grove/Concussion Clinic
Type
Children's Hospital
Rural
No
340B ID
PED243302-68
Medicare Provider Number
243302
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/9/2018
Participating Start Date
1/1/2019
Participating Approval Date
10/26/2018
Last Recertification Date
9/7/2021
Termination Date
Termination Reason
4/1/2022
Site closure
Contacts
Authorizing Official
Children's Hospitals and Clinics of Minnesota
Christa Steene-Lyons, Compliance Officer
(612) 813-6316
Primary Contact
Children's Hospitals and Clinics of Minnesota
Dirk Killelea, Pharmacy Manager - 340B
(612) 813-7161
Addresses
Street Address
7677 Elm Creek Boulevard
Suite 301
Maple Grove, MN 55369
Billing Address
Children's Business Campus
CBC-2-ACC
5901 Lincoln Drive
Edina, MN 55436
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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