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FAIRVIEW PHARMACY BURNSVILLE SCC
DSH240080AR UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Eye Clinics
Type
Disproportionate Share Hospital
340B ID
DSH240080AR
Entity Address
516 Delaware St. SE
PWB Clinic 9A
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 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
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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