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ALLINA HEALTH PHILLIPS EYE INSTITUTE PHA
DSH240057AB ABBOTT NORTHWESTERN HOSPITAL
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Covered Entity Details
Entity Name
ABBOTT NORTHWESTERN HOSPITAL
Subdivision Name
Allina Health Mental Health - Abbott Northwestern Clinic
Type
Disproportionate Share Hospital
340B ID
DSH240057AB
Entity Address
2855 Campus Drive
660
Plymouth, MN 55441-2665
Medicare Provider Number
240057
Outpatient Facility Provider Number
Participating Start Date
1/1/2021
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
ALLINA HEALTH PHILLIPS EYE INSTITUTE PHA
Pharmacy Address
2215 PARK AVE SOUTH
MINNEAPOLIS, MN 55404
Pharmacy Comments
Contract Details
Approval Date
4/12/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/25/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ann Rice, President
(612) 863-7737
Contract Pharmacy Representative
Allina Health
Tim J Gallagher, Director, Retail and Specialty Pharmacy
(612) 262-6654
Signed By Date
4/12/2021
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