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FAIRVIEW UNIVERSITY DISCHARGE PHARMACY
DSH240080K UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
UMMC Lakes Cancer Clinic and Infusion
Type
Disproportionate Share Hospital
340B ID
DSH240080K
Entity Address
5200 Fairview Blvd
Suite 1300
Wyoming, MN 55092
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 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
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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