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FAIRVIEW LAKES PHARMACY WYOMING
DSH240080BE UNIVERSITY OF MINNESOTA MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF MINNESOTA MEDICAL CENTER
Subdivision Name
UMMC Ridges Cancer Clinic and Infusion
Type
Disproportionate Share Hospital
340B ID
DSH240080BE
Entity Address
14101 Fairview Drive Suite 200
Burnsville, MN 55337
Medicare Provider Number
240080
Outpatient Facility Provider Number
Participating Start Date
10/1/2015
Last Recertification Date
8/26/2024
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
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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