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ALLINA HEALTH WESTHEALTH PHARMACY
DSH240115A MERCY HOSPITAL
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Covered Entity Details
Entity Name
MERCY HOSPITAL
Subdivision Name
Minnesota Perinatal Physicians
Type
Disproportionate Share Hospital
340B ID
DSH240115A
Entity Address
3960 Coon Rapids Blvd NW
220
Coon Rapids, MN 55433-2589
Medicare Provider Number
240115
Outpatient Facility Provider Number
Participating Start Date
10/1/2019
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
ALLINA HEALTH WESTHEALTH PHARMACY
Pharmacy Address
2855 CAMPUS DR
PLYMOUTH, MN 55441
Pharmacy Comments
Contract Details
Approval Date
4/14/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
1/1/2024
Contract Comments
Contacts
Covered Entity Signing Official
Phillip J. Krolik, VP, Finance
(651) 241-8827
Contract Pharmacy Representative
Allina Health
Tim J Gallagher, Director, Retail and Specialty Pharmacy
(612) 262-6654
Signed By Date
4/14/2021
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