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FAIRVIEW HOME INFUSION
DSH240214 MAPLE GROVE HOSPITAL
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Covered Entity Details
Entity Name
MAPLE GROVE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240214
Entity Address
9875 HOSPITAL DRIVE
MAPLE GROVE, MN 55369
Medicare Provider Number
240214
Participating Start Date
1/1/2018
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
FAIRVIEW HOME INFUSION
Pharmacy Address
711 B KASOTA AVENUE SE
MINNEAPOLIS, MN 55414
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Andy Cochrane, CEO
(763) 581-1550
Contract Pharmacy Representative
Fairview Health Services
Robert Beacher, President, Fairview Pharmacy Services LLC
(612) 672-7047
Signed By Date
4/16/2018
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