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FAIRVIEW EDINA PHARMACY
DSH240080U UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
UMMC Fairview Adult Infusion Clinic
Type
Disproportionate Share Hospital
340B ID
DSH240080U
Entity Address
606 24th Ave So
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
1/1/2020
Carve-In Effective Date
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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