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MERCY HOSPITAL PHC
DSH240020A Cambridge Medical Center
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Covered Entity Details
Entity Name
Cambridge Medical Center
Subdivision Name
Substance Abuse-Adult
Type
Disproportionate Share Hospital
340B ID
DSH240020A
Entity Address
701 S Dellwood St.
Cambridge, MN 55008-1920
Medicare Provider Number
240020
Outpatient Facility Provider Number
Participating Start Date
10/1/2012
Last Recertification Date
11/7/2017
Entity Termination Date
7/1/2018
Pharmacy Details
Pharmacy Name
MERCY HOSPITAL PHC
Pharmacy Address
4050 COON RAPIDS BLVD NW
COON RAPIDS, MN 55433-2522
Pharmacy Comments
Contract Details
Approval Date
1/10/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Gary A. Shaw, CEO
(763) 688-7804
Contract Pharmacy Representative
Jill Strykowski, Director of Pharmacy
(763) 236-4137
Signed By Date
1/10/2017
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