Contract Pharmacy Details

ALLINA HEALTH PHILLIPS EYE INSTITUTE PHA
DSH240196 PHILLIPS EYE INSTITUTE

Covered Entity Details

Entity Name

PHILLIPS EYE INSTITUTE

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH240196

Entity Address

2215 PARK AVENUE
MINNEAPOLIS, MN 55404

Medicare Provider Number

240196

Participating Start Date

10/1/2017

Last Recertification Date

11/9/2017

Entity Termination Date

7/1/2018

Pharmacy Details

Pharmacy Name

ALLINA HEALTH PHILLIPS EYE INSTITUTE PHA

Pharmacy Address

2215 PARK AVE SOUTH
MINNEAPOLIS, MN 55404

Pharmacy Comments

Contract Details

Approval Date

10/16/2017

Contract Begin Date

1/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Daniel Conrad, President, Phillips Eye Institute
(612) 775-8815

Contract Pharmacy Representative

allina
Ann Byre, Director of Pharmacy Services
(612) 262-5992

Signed By Date

10/16/2017

340B Drug Pricing Program Database