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ALLINA HEALTH NEW ULM PHARMACY
DSH240057G ABBOTT NORTHWESTERN HOSPITAL
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Covered Entity Details
Entity Name
ABBOTT NORTHWESTERN HOSPITAL
Subdivision Name
Courage Kenny Rehab Associates Pain Clinic & Pain Program / Pain Clinic
Type
Disproportionate Share Hospital
340B ID
DSH240057G
Entity Address
3915 Golden Valley Road
Golden Valley, MN 55407-3723
Medicare Provider Number
240057
Outpatient Facility Provider Number
Participating Start Date
10/1/2015
Last Recertification Date
9/9/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
ALLINA HEALTH NEW ULM PHARMACY
Pharmacy Address
1217 8TH ST N STE 1010
NEW ULM, MN 56073-1552
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
7/1/2022
Covered Entity Terminated
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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