Covered Entity Details

CAH241362-04 CENTRACARE HEALTH-MONTICELLO (Active) - information as of 6/3/2025 12:05:09 PM

Main Details

Name

CENTRACARE HEALTH-MONTICELLO

Subdivision Name

HVC Vascular Surgery Clinic - Vascular Surgery Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH241362-04

Medicare Provider Number

241362

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/9/2024

Participating Start Date

10/1/2024

Participating Approval Date

8/31/2024

Last Recertification Date

Contacts

Authorizing Official

CentraCare Health - Monticello
John Roland Hering, President
(763) 271-2445

Primary Contact

CentraCare Health-Monticello
Natalie Adams, Pharmacy Director
(763) 271-2425

Addresses

Street Address

1001 Hart BLVD
Suite150
Monticello, MN 55362

Billing Address

CentraCare Monticello
1013 Hart Blvd
Monticello, MN 55362

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
MN	1275872772	1275872772

Shipping Addresses

Shipping Address 1

CentraCare Monticello
1013 Hart Blvd
Monticello, MN 55362

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH241362-01	Child	CAH	CENTRACARE HEALTH-MONTICELLO	Monticello Cancer Center	1001 Hart Blvd	Monticello	MN	Active
CAH241362-02	Child	CAH	CENTRACARE HEALTH-MONTICELLO	CENTRACARE HEALTH - MONTICELLO MEDI	1107 HART BLVD	MONTICELLO	MN	Terminated
CAH241362-03	Child	CAH	CENTRACARE HEALTH-MONTICELLO	HVC Cardiology - Cardiology	1001 Hart BLVD	Monticello	MN	Active
CAH241362-04	Child	CAH	CENTRACARE HEALTH-MONTICELLO	HVC Vascular Surgery Clinic - Vascular Surgery Clinic	1001 Hart BLVD	Monticello	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Weaver, Jason Philip Divsion Director of Finance CentraCare Health-Monticello 7632712842	Hering, John Roland President CentraCare Health - Monticello 7632712445	11/25/2024 2:02 PM
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Weaver, Jason Philip Divsion Director of Finance CentraCare Health-Monticello 7632712842	8/31/2024 8:18 AM
Details	340B ID	Update	New Registration		CAH241362-04	8/31/2024 8:18 AM
Details	Entity Name	Update	New Registration	CCH-MONTICELLO	CENTRACARE HEALTH-MONTICELLO	8/31/2024 8:18 AM
Details	Entity Subname	Update	New Registration	HVC Vascular Surgery Clinic	HVC Vascular Surgery Clinic - Vascular Surgery Clinic	8/31/2024 8:18 AM
Dates	Participating Approval Date	Update	New Registration		8/31/2024 8:18:44 AM	8/31/2024 8:18 AM
Details	State	Update	New Registration	Pending	Approved	8/31/2024 8:18 AM
Dates	Signed By Date	Update	New Registration		8/30/2024 12:32:48 PM	8/31/2024 8:18 AM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	8/31/2024 8:18 AM
Addresses	Main Address	Insert	New Registration		1001 Hart BLVD Suite150 Monticello, MN 55362	7/9/2024 2:45 PM
Addresses	Billing Address	Insert	New Registration		CentraCare Monticello 1013 Hart Blvd Monticello, MN 55362	7/9/2024 2:45 PM
Addresses	Shipping Address	Insert	New Registration		CentraCare Monticello 1013 Hart Blvd Monticello, MN 55362	7/9/2024 2:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/9/2024 2:45 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1275872772	7/9/2024 2:45 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/9/2024 2:45 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1275872772	7/9/2024 2:45 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/9/2024 2:45 PM
Contacts	Authorizing Official	Insert	New Registration		Weaver, Jason Philip Divsion Director of Finance CentraCare Health-Monticello 7632712842	7/9/2024 2:45 PM
Contacts	Primary Contact	Insert	New Registration		Adams, Natalie Pharmacy Director CentraCare Health-Monticello 7632712425	7/9/2024 2:45 PM
Details	Assistance Received From Date	Insert	New Registration			7/9/2024 2:45 PM
Details	Assistance Received To Date	Insert	New Registration			7/9/2024 2:45 PM
Details	Last Recertification Date	Insert	New Registration			7/9/2024 2:45 PM
Details	Grant Number	Insert	New Registration			7/9/2024 2:45 PM
Details	340B ID	Insert	New Registration			7/9/2024 2:45 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/9/2024 2:45 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/9/2024 2:45 PM
Details	Medicare Provider Number	Insert	New Registration		241362	7/9/2024 2:45 PM
Details	Entity Name	Insert	New Registration		CCH-MONTICELLO	7/9/2024 2:45 PM
Details	NOFO Number	Insert	New Registration			7/9/2024 2:45 PM
Details	Program Code	Insert	New Registration		CAH	7/9/2024 2:45 PM
Details	Entity Subname	Insert	New Registration		HVC Vascular Surgery Clinic	7/9/2024 2:45 PM
Dates	Participating Approval Date	Insert	New Registration			7/9/2024 2:45 PM
Details	State	Insert	New Registration		Pending	7/9/2024 2:45 PM
Dates	Registration Date	Insert	New Registration		7/9/2024 2:45:10 PM	7/9/2024 2:45 PM
Dates	Signed By Date	Insert	New Registration			7/9/2024 2:45 PM
Dates	Start Date	Insert	New Registration			7/9/2024 2:45 PM
Terminations	Termination Comments	Insert	New Registration			7/9/2024 2:45 PM
Terminations	Termination Date	Insert	New Registration			7/9/2024 2:45 PM
Terminations	Termination Effective Date	Insert	New Registration			7/9/2024 2:45 PM
Terminations	Termination Reason	Insert	New Registration			7/9/2024 2:45 PM