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ALLINA HEALTH MERCY PHARMACY
DSH240115E MERCY HOSPITAL
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Covered Entity Details
Entity Name
MERCY HOSPITAL
Subdivision Name
Courage Kenney Rehabilitation Institute
Type
Disproportionate Share Hospital
340B ID
DSH240115E
Entity Address
11850 Blackfoot Street NW
Suite 130
Coon Rapids, MN 55433
Medicare Provider Number
240115
Outpatient Facility Provider Number
Participating Start Date
10/1/2016
Last Recertification Date
11/9/2017
Entity Termination Date
7/1/2018
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
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Covered Entity Terminated
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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