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PED243300-06 GILLETTE CHILDREN'S SPECIALTY HEALTHCARE (Active)
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Main Details
Name
GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Subdivision Name
PHALEN PEDS CLINIC
Type
Children's Hospital
Rural
No
340B ID
PED243300-06
Medicare Provider Number
243300
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/3/2023
Participating Start Date
7/1/2023
Participating Approval Date
4/28/2023
Last Recertification Date
8/14/2024
Contacts
Authorizing Official
Gillette Children's Specialty Healthcare
Patrick Michael Nolan, Chief Financial Officer
(651) 312-3105
Primary Contact
Gillette Children's Specialty Healthcare - Saint Paul, MN
Kristen Beyer, Pharmacy Manager
(651) 726-2876
Addresses
Street Address
435 PHALEN BOULEVARD
ST. PAUL, MN 55130-5302
Billing Address
Gillette Children's Specialty Healthcare
200 University Avenue East
St. Paul, MN 55101
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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