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ALLINA HEALTH HEART HOSPITAL PHARMACY
DSH240057C ABBOTT NORTHWESTERN HOSPITAL
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Covered Entity Details
Entity Name
ABBOTT NORTHWESTERN HOSPITAL
Subdivision Name
Minnesota Perinatal Physicians Maple Grove / MG High Risk Perinatal Clinic
Type
Disproportionate Share Hospital
340B ID
DSH240057C
Entity Address
9600 Upland Lane N
Suite 180
Maple Grove, MN 55369-4495
Medicare Provider Number
240057
Outpatient Facility Provider Number
Participating Start Date
10/1/2015
Last Recertification Date
9/8/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
ALLINA HEALTH HEART HOSPITAL PHARMACY
Pharmacy Address
920 E 28TH ST STE H1254
MINNEAPOLIS, MN 55407
Pharmacy Comments
Contract Details
Approval Date
10/2/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Brian Weinreis, Chief Financial Officer
(612) 863-1920
Contract Pharmacy Representative
allina
Ann Byre, Director of Pharmacy Services
(612) 262-5992
Signed By Date
10/2/2015
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