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ALLINA HEALTH MERCY PHARMACY
DSH240115G MERCY HOSPITAL
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Covered Entity Details
Entity Name
MERCY HOSPITAL
Subdivision Name
Adult Mental Health Outpatient Program
Type
Disproportionate Share Hospital
340B ID
DSH240115G
Entity Address
520 Osborne Rd
330 & 350
Fridley, MN 55432
Medicare Provider Number
240115
Outpatient Facility Provider Number
Participating Start Date
10/1/2019
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
ALLINA HEALTH MERCY PHARMACY
Pharmacy Address
11850 BLACKFOOT ST. NW
STE 190
COON RAPIDS, MN 55433
Pharmacy Comments
Contract Details
Approval Date
10/10/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
1/1/2024
Contract Comments
Contacts
Covered Entity Signing Official
Sara Criger, SVP President-MCY
(763) 236-8205
Contract Pharmacy Representative
allina
Ann Byre, Director of Pharmacy Services
(612) 262-5992
Signed By Date
10/10/2016
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