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FAIRVIEW UNIVERSITY CLINIC PHARMACY
DSH240080BD UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Psychiatric Emergency Room
Type
Disproportionate Share Hospital
340B ID
DSH240080BD
Entity Address
2312 S. 6th Street
Minneapolis, MN 55454
Medicare Provider Number
240080
Outpatient Facility Provider Number
Participating Start Date
4/1/2015
Last Recertification Date
11/21/2017
Entity Termination Date
4/1/2018
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
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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