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FAIRVIEW EDINA PHARMACY
DSH240080AS UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Pediatric ENT Clinics
Type
Disproportionate Share Hospital
340B ID
DSH240080AS
Entity Address
701 25th Ave S
Suite 200
Minneapolis, MN 55454
Medicare Provider Number
240080
Outpatient Facility Provider Number
Participating Start Date
7/1/2012
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
FAIRVIEW EDINA PHARMACY
Pharmacy Address
6401 FRANCE AVE S # SL-1
EDINA, MN 55435-2104
Pharmacy Comments
Contract Details
Approval Date
10/17/2019
Contract Begin Date
10/17/2019
Carve-In Effective Date
10/17/2019
Contract Comments
Contacts
Covered Entity Signing Official
Trudi Noel Trysla, Chief Legal Officer
(612) 672-6382
Contract Pharmacy Representative
Fairview Pharmacy Services
Kyle Skiermont, Chief Operating Officer
(612) 672-7446
Signed By Date
10/17/2019
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