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MAYO CLINIC PHARMACY
SCH240043-43 MAYO CLINIC HEALTH SYSTEM-ALBERT LEA
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Covered Entity Details
Entity Name
MAYO CLINIC HEALTH SYSTEM-ALBERT LEA
Subdivision Name
Mayo Clinic Health System-Austin - Endoscopy
Type
Sole Community Hospital
340B ID
SCH240043-43
Entity Address
1000 1st Drive NW
Austin, MN 55912
Medicare Provider Number
240043
Outpatient Facility Provider Number
Participating Start Date
1/1/2021
Last Recertification Date
9/15/2021
Entity Termination Date
10/1/2022
Pharmacy Details
Pharmacy Name
MAYO CLINIC PHARMACY
Pharmacy Address
3551 Commercial Dr SW
Rochester, MN 55902
Pharmacy Comments
Contract Details
Approval Date
4/7/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kristin S. Johnson, Vice Chair Administration SE MN
(507) 434-9806
Contract Pharmacy Representative
Mayo Clinic
Mike O'Brien, Director
(715) 838-6762
Signed By Date
4/7/2022
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