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FAIRVIEW SPECIALTY SERVICES PHARMACY
CAH521329-00 ST MARYS HOSPITAL OF SUPERIOR
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Covered Entity Details
Entity Name
ST MARYS HOSPITAL OF SUPERIOR
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521329-00
Entity Address
3500 TOWER AVE
SUPERIOR, WI 54880
Medicare Provider Number
521329
Participating Start Date
9/30/2010
Last Recertification Date
8/19/2024
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
Terry Jacobson, Administrator
(715) 817-7014
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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