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ALLINA HEALTH MERCY PHARMACY
DSH240071B Allina Health Faribault Medical Center
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Covered Entity Details
Entity Name
Allina Health Faribault Medical Center
Subdivision Name
Courage Kenny Rehabilitation Institute
Type
Disproportionate Share Hospital
340B ID
DSH240071B
Entity Address
35 State Ave
Faribault, MN 55021-6339
Medicare Provider Number
240071
Outpatient Facility Provider Number
Participating Start Date
1/1/2022
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
ALLINA HEALTH MERCY PHARMACY
Pharmacy Address
11850 BLACKFOOT ST. NW
STE 190
COON RAPIDS, MN 55433
Pharmacy Comments
Contract Details
Approval Date
3/27/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
4/1/2024
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
3/27/2024
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