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FAIRVIEW PHARMACY BURNSVILLE SCC
DSH240080AK UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Derm Rheumatology Clinic
Type
Disproportionate Share Hospital
340B ID
DSH240080AK
Entity Address
909 Fulton Street SE
Clinics and Surgery Center, 3rd Floor East
Minneapolis, MN 55455
Medicare Provider Number
240080
Outpatient Facility Provider Number
Participating Start Date
7/1/2012
Last Recertification Date
11/21/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
FAIRVIEW PHARMACY BURNSVILLE SCC
Pharmacy Address
14101 FAIRVIEW DRIVE
SUITE 100
BURNSVILLE, MN 55337
Pharmacy Comments
Contract Details
Approval Date
12/9/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Daniel M. Fromm, Sr. VP and CFO, Fairview Health Services
(612) 672-4976
Contract Pharmacy Representative
University of Minnesota Medical Center
Charles Cooper, 340B Program Manager
(612) 672-5179
Signed By Date
12/9/2016
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