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ALLINA HEALTH FARIBAULT PHARMACY
DSH240038F United Hospital
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Covered Entity Details
Entity Name
United Hospital
Subdivision Name
Minnesota Perinatal Physicians - United
Type
Disproportionate Share Hospital
340B ID
DSH240038F
Entity Address
347 North Smith Avenue
204
Saint Paul, MN 55102
Medicare Provider Number
240038
Outpatient Facility Provider Number
Participating Start Date
10/1/2013
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
ALLINA HEALTH FARIBAULT PHARMACY
Pharmacy Address
200 STATE AVE
FARIBAULT, MN 55021
Pharmacy Comments
Contract Details
Approval Date
3/28/2024
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
3/28/2024
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