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WALGREEN CO.
SCH240166-00 MAYO CLINIC HEALTH SYSTEM-FAIRMONT
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Covered Entity Details
Entity Name
MAYO CLINIC HEALTH SYSTEM-FAIRMONT
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH240166-00
Entity Address
800 MEDICAL CENTER DRIVE
FAIRMONT, MN 56031
Medicare Provider Number
240166
Participating Start Date
7/1/2021
Last Recertification Date
8/30/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
WALGREENS SPECIALTY PHARMACY #15309
2100 LYNDALE AVE S STE A
MINNEAPOLIS, MN 55405
Pharmacy Comments
Contract Details
Approval Date
4/11/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Travis C. Paul, Regional Chair of Administration SWMN
(608) 392-9716
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/11/2023
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