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GRAND ST. PAUL CVS, L.L.C.
DSH240115 MERCY HOSPITAL
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Covered Entity Details
Entity Name
MERCY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240115
Entity Address
4050 COON RAPIDS BLVD
COON RAPIDS, MN 55433
Medicare Provider Number
240115
Participating Start Date
10/1/2019
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
GRAND ST. PAUL CVS, L.L.C.
Pharmacy Address
CVS PHARMACY # 16646
215 BALSAM ST N
CAMBRIDGE, MN 55008
Pharmacy Comments
Contract Details
Approval Date
10/11/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tony M Collins-Kwong, Director, Strategic Sourcing and Services, Pharmacy Services
(612) 262-4785
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/11/2023
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