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ALLINA HEALTH HEART HOSPITAL PHARMACY
DSH240115K MERCY HOSPITAL
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Covered Entity Details
Entity Name
MERCY HOSPITAL
Subdivision Name
Courage Kenny Rehabilitation Institute - Mercy Hospital, Unity Campus - PT, OT, Lymphedema
Type
Disproportionate Share Hospital
340B ID
DSH240115K
Entity Address
480 Osborne Rd NE
Suite 200
Fridley, MN 55432-2718
Medicare Provider Number
240115
Outpatient Facility Provider Number
Participating Start Date
10/1/2019
Last Recertification Date
9/1/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
ALLINA HEALTH HEART HOSPITAL PHARMACY
Pharmacy Address
920 E 28TH ST STE H1254
MINNEAPOLIS, MN 55407
Pharmacy Comments
Contract Details
Approval Date
10/9/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Paula Inman, Director of Finance
(763) 236-2176
Contract Pharmacy Representative
allina
Ann Byre, Director of Pharmacy Services
(612) 262-5992
Signed By Date
10/9/2019
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