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FAIRVIEW EDINA PHARMACY
DSH240080AN UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Bleeding and Clotting Disorders
Type
Disproportionate Share Hospital
340B ID
DSH240080AN
Entity Address
909 Fulton Street SE
Clinics and Surgery Center, 3rd Floor West
Minneapolis, MN 55455
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 EDINA PHARMACY
Pharmacy Address
6363 FRANCE AVENUE SOUTH
EDINA, MN 55435
Pharmacy Comments
Contract Details
Approval Date
12/9/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
10/1/2016
Contract Comments
Contract Termination Date
Termination Reason
1/15/2020
Business decision by covered entity and/or pharmacy
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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