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FAIRVIEW EDINA PHARMACY
DSH240080AL UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Blood and Marrow Transplant Clinic
Type
Disproportionate Share Hospital
340B ID
DSH240080AL
Entity Address
909 Fulton Street SE
Clinics and Surgery Center, 2nd Floor North
Minneapolis, MN 55455
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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