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FAIRVIEW PHARMACY MAPLEWOOD
DSH240210D HEALTHEAST ST JOHNS HOSPITAL
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Covered Entity Details
Entity Name
HEALTHEAST ST JOHNS HOSPITAL
Subdivision Name
HealthEast Vascular Center
Type
Disproportionate Share Hospital
340B ID
DSH240210D
Entity Address
1875 Woodwinds Drive
Suite 150
Woodbury, MN 55125
Medicare Provider Number
240210
Outpatient Facility Provider Number
240210
Participating Start Date
10/1/2014
Last Recertification Date
9/15/2022
Entity Termination Date
10/1/2023
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
10/1/2023
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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