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FAIRVIEW SPECIALTY SERVICES PHARMACY
CAH241340-00 NORTHERN PINES MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTHERN PINES MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241340-00
Entity Address
5211 HIGHWAY 110
AURORA, MN 55705
Medicare Provider Number
241340
Participating Start Date
10/1/2012
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
FAIRVIEW SPECIALTY SERVICES PHARMACY
Pharmacy Address
711 KASOTA AVENUE SE, SUITE A
MINNEAPOLIS, MN 55414
Pharmacy Comments
Contract Details
Approval Date
4/13/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/15/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Laura Ackman, President
(218) 229-2211 Ext: 4222
Contract Pharmacy Representative
University of Minnesota Medical Center
Jesse Peterson, 340B Program Director
(612) 672-5179
Signed By Date
4/13/2018
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