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FAIRVIEW LAKES PHARMACY WYOMING
DSH240080BR UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Breast Center - Oncology
Type
Disproportionate Share Hospital
340B ID
DSH240080BR
Entity Address
909 Fulton Street SE
Clinics and Surgery Center, 2nd Floor
Suite 202
Minneapolis, MN 55455
Medicare Provider Number
240080
Outpatient Facility Provider Number
Participating Start Date
1/1/2019
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
FAIRVIEW LAKES PHARMACY WYOMING
Pharmacy Address
5200 FAIRVIEW BOULEVARD
WYOMING, MN 55092
Pharmacy Comments
Contract Details
Approval Date
1/17/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel M. Fromm, Sr. VP and CFO, Fairview Health Services
(612) 672-4976
Contract Pharmacy Representative
Fairview Pharmacy Services
Kyle Skiermont, Chief Operating Officer
(612) 672-7446
Signed By Date
1/17/2019
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