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ALLINA HEALTH WESTHEALTH PHARMACY
DSH240115G MERCY HOSPITAL
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Covered Entity Details
Entity Name
MERCY HOSPITAL
Subdivision Name
Adult Mental Health Outpatient Program
Type
Disproportionate Share Hospital
340B ID
DSH240115G
Entity Address
520 Osborne Rd
330 & 350
Fridley, MN 55432
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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