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NORTH MEMORIAL PHARMACY MAPLE GROVE
DSH240214 MAPLE GROVE HOSPITAL
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Covered Entity Details
Entity Name
MAPLE GROVE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240214
Entity Address
9875 HOSPITAL DRIVE
MAPLE GROVE, MN 55369
Medicare Provider Number
240214
Participating Start Date
1/1/2018
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
NORTH MEMORIAL PHARMACY MAPLE GROVE
Pharmacy Address
9825 HOSPITAL DR STE 100
MAPLE GROVE, MN 55369-4770
Pharmacy Comments
Contract Details
Approval Date
10/14/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Andy Cochrane, CEO
(763) 581-1550
Contract Pharmacy Representative
North Memorial Health
Barbara Hintzen, Pharmacy Program Supervisor
(763) 581-2099
Signed By Date
10/14/2021
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