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SUPERVALU PHARMACIES INC
FQHCLA262 UNIVERSAL MEDICAL SERVICES, INC.
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Covered Entity Details
Entity Name
UNIVERSAL MEDICAL SERVICES, INC.
Subdivision Name
AXIS MEDICAL CENTER
Type
Health Center Program Look-Alike
340B ID
FQHCLA262
Entity Address
1801 NICOLLET AVENUE
FLOOR 1
MINNEAPOLIS, MN 55403
Grant Number
LALCS00028
Participating Start Date
7/1/2010
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
SUPERVALU PHARMACIES INC
Pharmacy Address
DBA CUB PHARMACY #1598/682
12595 CENTRAL AVE NE
BLAINE, MN 55434
Pharmacy Comments
Contract Details
Approval Date
1/17/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Theodore James, CEO
(612) 823-2947 Ext: 826
Contract Pharmacy Representative
Cub Pharmacy
Aaron Sapp, Contact Person
(952) 828-4026
Signed By Date
1/17/2019
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