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FAIRVIEW PHARMACY ST. PAUL
DSH240063B HEALTHEAST ST JOSEPHS HOSPITAL
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Covered Entity Details
Entity Name
HEALTHEAST ST JOSEPHS HOSPITAL
Subdivision Name
HealthEast Hospice
Type
Disproportionate Share Hospital
340B ID
DSH240063B
Entity Address
1700 University Avenue West
St. Paul, MN 55104
Medicare Provider Number
240063
Outpatient Facility Provider Number
241504
Participating Start Date
7/1/2017
Last Recertification Date
8/29/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
FAIRVIEW PHARMACY ST. PAUL
Pharmacy Address
17 WEST EXCHANGE STREET, SUITE 150
SAINT PAUL, MN 55102
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
4/1/2019
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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