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FAIRVIEW HOME INFUSION DULUTH
DSH240047 St. Luke's Hospital of Duluth
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Covered Entity Details
Entity Name
St. Luke's Hospital of Duluth
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240047
Entity Address
915 East First Street
Duluth, MN 55805
Medicare Provider Number
240047
Participating Start Date
10/1/2013
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
FAIRVIEW HOME INFUSION DULUTH
Pharmacy Address
1527 LONDON RD
DULUTH, MN 55812-1617
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eric Lohn, Vice President/CFO
(218) 249-5475
Contract Pharmacy Representative
University of Minnesota Medical Center
Charles Cooper, 340B Program Manager
(612) 672-5179
Signed By Date
10/15/2018
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