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PARK NICOLLET PHARMACY #87017
DSH240106 REGIONS HOSPITAL
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Covered Entity Details
Entity Name
REGIONS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240106
Entity Address
640 JACKSON ST.
ST. PAUL, MN 55101
Medicare Provider Number
240106
Participating Start Date
12/1/1992
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
PARK NICOLLET PHARMACY #87017
Pharmacy Address
3800 PARK NICOLLET BLVD STE 1170
ST LOUIS PARK, MN 55416-2527
Pharmacy Comments
Contract Details
Approval Date
10/17/2012
Contract Begin Date
10/17/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
HEIDI CONRAD, CFO
(651) 254-0900
Contract Pharmacy Representative
Rick Bruzek, V.P. Pharmacy Services
(952) 967-5841
Signed By Date
10/15/2012
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