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ALLINA HEALTH MERCY PHARMACY
DSH240115D MERCY HOSPITAL
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Covered Entity Details
Entity Name
MERCY HOSPITAL
Subdivision Name
Mercy Same Day Surgery Center
Type
Disproportionate Share Hospital
340B ID
DSH240115D
Entity Address
11850 Blackfoot Street NW
Suite 200
200
Coon Rapids, MN 55433-2593
Medicare Provider Number
240115
Outpatient Facility Provider Number
Participating Start Date
10/1/2019
Last Recertification Date
9/4/2020
Entity Termination Date
10/1/2021
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
10/1/2021
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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