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FAIRVIEW UNIVERSITY DISCHARGE PHARMACY
DSH240080AY UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Autism Clinic
Type
Disproportionate Share Hospital
340B ID
DSH240080AY
Entity Address
2512 S 7th St
Minneapolis, MN 55455
Medicare Provider Number
240080
Outpatient Facility Provider Number
Participating Start Date
4/1/2015
Last Recertification Date
9/3/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
FAIRVIEW UNIVERSITY DISCHARGE PHARMACY
Pharmacy Address
500 HARVARD ST SE # 2-130K
MMC 812
MINNEAPOLIS, MN 55455-0363
Pharmacy Comments
Contract Details
Approval Date
10/17/2019
Contract Begin Date
10/17/2019
Carve-In Effective Date
10/17/2019
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
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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