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FAIRVIEW PHARMACY MAPLEWOOD
DSH240210C HEALTHEAST ST JOHNS HOSPITAL
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Covered Entity Details
Entity Name
HEALTHEAST ST JOHNS HOSPITAL
Subdivision Name
HEALTHEAST VASCULAR CENTER ST PAUL
Type
Disproportionate Share Hospital
340B ID
DSH240210C
Entity Address
17 W EXCHANGE ST
Suite 140
ST PAUL, MN 55102-1225
Medicare Provider Number
240210
Outpatient Facility Provider Number
240210
Participating Start Date
10/1/2014
Last Recertification Date
9/15/2022
Entity Termination Date
7/1/2023
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
7/1/2023
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
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