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FAIRVIEW SPECIALTY SERVICES PHARMACY
DSH240002 ST MARYS MEDICAL CENTER
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Covered Entity Details
Entity Name
ST MARYS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240002
Entity Address
402 E 2ND STREET
DULUTH, MN 55805
Medicare Provider Number
240002
Participating Start Date
7/1/2011
Last Recertification Date
8/30/2023
Entity Termination Date
10/1/2024
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
James M. Garvey, SVP Hospital Operations East Region
(218) 786-4878
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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