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FAIRVIEW SPECIALTY SERVICES PHARMACY
CAH241309-00 PINE MEDICAL CENTER
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Covered Entity Details
Entity Name
PINE MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241309-00
Entity Address
705 LUNDORFF DR
SANDSTONE, MN 55072
Medicare Provider Number
241309
Participating Start Date
7/1/2011
Last Recertification Date
8/21/2024
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
Scott Nigon, CFO
(218) 786-3212
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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