Contract Pharmacy Details

FAIRVIEW PHARMACY MAPLEWOOD
DSH240210F HEALTHEAST ST JOHNS HOSPITAL

Covered Entity Details

Entity Name

HEALTHEAST ST JOHNS HOSPITAL

Subdivision Name

Pain Center - Pain Center

Type

Disproportionate Share Hospital

340B ID

DSH240210F

Entity Address

1600 St. John's Blvd, Suite 101
Maplewood, MN 55109

Medicare Provider Number

240210

Outpatient Facility Provider Number

Participating Start Date

10/1/2023

Last Recertification Date

8/26/2024

Entity Termination Date

7/1/2025

Pharmacy Details

Pharmacy Name

FAIRVIEW PHARMACY MAPLEWOOD

Pharmacy Address

2945 HAZELWOOD STREET SUITE 105
MAPLEWOOD, MN 55109

Pharmacy Comments

Contract Details

Approval Date

10/12/2018

Contract Begin Date

1/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2022
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Daniel M. Fromm, Sr. VP and CFO, Fairview Health Services
(612) 672-4976

Contract Pharmacy Representative

Fairview
Tim Affeldt, VP of Specialty/Infusion Operations
(612) 672-5127

Signed By Date

10/12/2018

340B Drug Pricing Program Database