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ALLINA HEALTH MERCY PHARMACY
DSH240115F MERCY HOSPITAL
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Covered Entity Details
Entity Name
MERCY HOSPITAL
Subdivision Name
Courage Kenny Kids
Type
Disproportionate Share Hospital
340B ID
DSH240115F
Entity Address
3960 Coon Rapids Blvd NW
123
Coon Rapids, MN 55433-2569
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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