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ALLINA HEALTH HEART HOSPITAL PHARMACY
DSH240115AG MERCY HOSPITAL
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Covered Entity Details
Entity Name
MERCY HOSPITAL
Subdivision Name
Unity 2W Medical Surgical Oncology - Medical/Surgical
Type
Disproportionate Share Hospital
340B ID
DSH240115AG
Entity Address
550 Osborne Rd NE
Fridley, MN 55432
Medicare Provider Number
240115
Outpatient Facility Provider Number
Participating Start Date
10/1/2022
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
ALLINA HEALTH HEART HOSPITAL PHARMACY
Pharmacy Address
920 E 28TH ST STE H1254
MINNEAPOLIS, MN 55407
Pharmacy Comments
Contract Details
Approval Date
12/2/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
1/1/2024
Contract Comments
Contacts
Covered Entity Signing Official
Tony M Collins-Kwong, Director, Strategic Sourcing and Services, Pharmacy Services
(612) 262-4785
Contract Pharmacy Representative
Allina Health
Tim J Gallagher, Director, Retail and Specialty Pharmacy
(612) 262-6654
Signed By Date
12/2/2023
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