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ALLINA HEALTH MERCY PHARMACY
DSH240057F ABBOTT NORTHWESTERN HOSPITAL
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Covered Entity Details
Entity Name
ABBOTT NORTHWESTERN HOSPITAL
Subdivision Name
Courage Kenny Rehab Associates Pain Program
Type
Disproportionate Share Hospital
340B ID
DSH240057F
Entity Address
3915 Golden Valley Road
Golden Valley, MN 55422-4249
Medicare Provider Number
240057
Outpatient Facility Provider Number
Participating Start Date
10/1/2015
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
ALLINA HEALTH MERCY PHARMACY
Pharmacy Address
11850 BLACKFOOT ST. NW
STE 190
COON RAPIDS, MN 55433
Pharmacy Comments
Contract Details
Approval Date
4/12/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
1/1/2024
Contract Comments
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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