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ALLINA HEALTH HEART HOSPITAL PHARMACY
DSH240038H United Hospital
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Covered Entity Details
Entity Name
United Hospital
Subdivision Name
Apple Valley Medical Imaging
Type
Disproportionate Share Hospital
340B ID
DSH240038H
Entity Address
14655 Galaxie Avenue
Apple Valley, MN 55124
Medicare Provider Number
240038
Outpatient Facility Provider Number
Participating Start Date
10/1/2013
Last Recertification Date
9/4/2020
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
10/14/2019
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
Phillip J. Krolik, VP, Finance
(651) 241-8827
Contract Pharmacy Representative
allina
Ann Byre, Director of Pharmacy Services
(612) 262-5992
Signed By Date
10/14/2019
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