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FAIRVIEW UNIVERSITY CLINIC PHARMACY
DSH240080M UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Pediatric Explorer Clinic
Type
Disproportionate Share Hospital
340B ID
DSH240080M
Entity Address
2450 Riverside Ave
East 12th floor
Minneapolis, MN 55454
Medicare Provider Number
240080
Outpatient Facility Provider Number
Participating Start Date
7/1/2012
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
FAIRVIEW UNIVERSITY CLINIC PHARMACY
Pharmacy Address
909 FULTON STREET SE, 1ST FLOOR
MAIL CODE 2121AA
MINNEAPOLIS, MN 55455
Pharmacy Comments
Contract Details
Approval Date
12/9/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
10/1/2016
Contract Comments
Contacts
Covered Entity Signing Official
Daniel M. Fromm, Sr. VP and CFO, Fairview Health Services
(612) 672-4976
Contract Pharmacy Representative
Fairview Pharmacy Services
Kyle Skiermont, Chief Operating Officer
(612) 672-7446
Signed By Date
12/9/2016
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