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FAIRVIEW PHARMACY NORTH BRANCH
DSH240080 UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240080
Entity Address
500 HARVARD ST. SE
MINNEAPOLIS, MN 55455
Medicare Provider Number
240080
Participating Start Date
7/1/2006
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
FAIRVIEW PHARMACY NORTH BRANCH
Pharmacy Address
5366 - 386TH STREET
NORTH BRANCH, MN 55056
Pharmacy Comments
Contract Details
Approval Date
4/11/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Trudi Noel Trysla, Chief Legal Officer
(612) 672-6382
Contract Pharmacy Representative
Fairview Pharmacy Services
John Pastor, System VP Pharmacy and Respiratory Care
(612) 672-5153
Signed By Date
4/11/2024
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