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FAIRVIEW LAKES PHARMACY WYOMING
DSH240080AZ UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Aphaeresis Blood Donation
Type
Disproportionate Share Hospital
340B ID
DSH240080AZ
Entity Address
2450 Riverside Ave
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 LAKES PHARMACY WYOMING
Pharmacy Address
5200 FAIRVIEW BOULEVARD
WYOMING, MN 55092
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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