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FAIRVIEW LAKES PHARMACY WYOMING
DSH240080AY UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
Autism Clinic
Type
Disproportionate Share Hospital
340B ID
DSH240080AY
Entity Address
2512 S 7th St
Minneapolis, MN 55455
Medicare Provider Number
240080
Outpatient Facility Provider Number
Participating Start Date
4/1/2015
Last Recertification Date
9/3/2020
Entity Termination Date
10/1/2021
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
10/1/2016
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
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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