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FAIRVIEW UNIVERSITY CLINIC PHARMACY
DSH240080R UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Pediatric Discovery Clinic
Type
Disproportionate Share Hospital
340B ID
DSH240080R
Entity Address
2512 S 7th St
Suite 300
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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