Covered Entity Details

DSH430027ED Sanford USD Medical Center (Active) - information as of 5/4/2025 10:18:44 PM

Main Details

Name

Sanford USD Medical Center

Subdivision Name

Rock Rapids Clinic - Rock Rapids Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH430027ED

Medicare Provider Number

430027

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/12/2024

Participating Start Date

10/1/2024

Participating Approval Date

7/18/2024

Last Recertification Date

Contacts

Authorizing Official

Sanford Health
Eric Lucas Vanden Hull, Vice President of Finance - Sioux Falls HSD
(712) 261-5275

Primary Contact

Sanford USD Medical Center
Alyssa O Howard, Director of Pharmacy
(605) 695-1697

Addresses

Street Address

104 Buncombe Dr
Rock Rapids, IA 51246-1003

Billing Address

Sanford USD Medical Center
1305 W 18th St
Sioux Falls, SD 57117-5039

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		1972844793,1093090342,1821017880
IA		1972844793
NE		1972844793

Shipping Addresses

Shipping Address 1

Sanford USD Medical Center
1305 W 18th St
Sioux Falls, SD 57117-5039

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
DSH430027A	Child	DSH	Sanford USD Medical Center	Sanford 26th & Sycamore Family Medicine	4405 E 26th St.	Sioux Falls	SD	Active
DSH430027AB	Child	DSH	Sanford USD Medical Center	Sanford Cancer Center Oncology	1309 W. 17th Street	Sioux Falls	SD	Active
DSH430027AC	Child	DSH	Sanford USD Medical Center	Sanford Medical Center Cancer Infusion Center	1309 W. 17th Street Suite 101	Sioux Falls	SD	Active
DSH430027AD	Child	DSH	Sanford USD Medical Center	SANFORD EAR, NOSE & THROAT CLINIC	1310 W 22ND ST	SIOUX FALLS	SD	Active
DSH430027AE	Child	DSH	Sanford USD Medical Center	SANFORD ORTHOPEDICS AND SPORTS MEDICINE	1210 W 18 ST	SIOUX FALLS	SD	Active
DSH430027AF	Child	DSH	Sanford USD Medical Center	Sanford 26th & Sycamore Acute Care and Orthopedic Fast Track Clinic	4405 E 26TH ST.	SIOUX FALLS	SD	Active
DSH430027AG	Child	DSH	Sanford USD Medical Center	SANFORD 32nd & Ellis Acute Care and Orthopedic Fast Track Clinic	2601 S Ellis Rd.	SIOUX FALLS	SD	Active
DSH430027AH	Child	DSH	Sanford USD Medical Center	Sanford 69th & Minnesota Acute Care and Orthopedic Fast Track Clinic	6110 S MINNESOTA AVE.	SIOUX FALLS	SD	Active
DSH430027AJ	Child	DSH	Sanford USD Medical Center	SANFORD CHILDREN'S 26TH & SYCAMORE CLINIC	4405 E 26TH ST	SIOUX FALLS	SD	Active
DSH430027AK	Child	DSH	Sanford USD Medical Center	SANFORD GENERAL SURGERY CLINIC	6110 S MINNESOTA AVE	SIOUX FALLS	SD	Terminated
DSH430027AL	Child	DSH	Sanford USD Medical Center	Sanford Infectious Disease & Travel Medicine Clinic	1420 W 22 St	SIOUX FALLS	SD	Active
DSH430027AM	Child	DSH	Sanford USD Medical Center	SANFORD USD FAMILY MEDICINE	2701S KIWANIS AVE	SIOUX FALLS	SD	Terminated
DSH430027AN	Child	DSH	Sanford USD Medical Center	SANFORD CARDIOVASCULAR INSTITUTE	1301 W 18TH ST	SIOUX FALLS	SD	Active
DSH430027AP	Child	DSH	Sanford USD Medical Center	SANFORD NUCLEAR MEDICINE CLINIC	1205 S GRANGE AVE	SIOUX FALLS	SD	Terminated
DSH430027AQ	Child	DSH	Sanford USD Medical Center	Sanford Dialysis	300 S Byron Boulevard	Chamberlain	SD	Active
DSH430027AR	Child	DSH	SANFORD USD MEDICAL CENTER	Sanford Dialysis Madison	903 N Washington Avenue	Madison	SD	Terminated
DSH430027AS	Child	DSH	SANFORD USD MEDICAL CENTER	Sanford Dialysis Wagner	111 Washington Avenue NW	Wagner	SD	Terminated
DSH430027AT	Child	DSH	Sanford USD Medical Center	SANFORD PAIN CENTER	1321 West 22nd Street	SIOUX FALLS	SD	Terminated
DSH430027AU	Child	DSH	Sanford USD Medical Center	Sanford 69th & Louise Family Medicine	6101 S LOUISE AVE	SIOUX FALLS	SD	Active
DSH430027AV	Child	DSH	Sanford USD Medical Center	Sanford Children's 69th & Louise Clinic	6101 S LOUISE AVE	SIOUX FALLS	SD	Active
DSH430027AW	Child	DSH	Sanford USD Medical Center	SANFORD MEDICAL CENTER / Sanford Children's Residency Clinic	6101 S LOUISE AVE	SIOUX FALLS	SD	Terminated
DSH430027AX	Child	DSH	Sanford USD Medical Center	Sanford Allergy and Immunology Clinic	1321 W. 22nd Street	Sioux Falls	SD	Active
DSH430027AY	Child	DSH	Sanford USD Medical Center	SANFORD OBSTETRICS & GYNECOLOGY 32N - Womens Health, Obstetrics and Gynecology	2601 S ELLIS RD	SIOUX FALLS	SD	Active
DSH430027AZ	Child	DSH	Sanford USD Medical Center	SANFORD CHILDREN'S 32ND & ELLIS CLI - Pediatrics	2601 S ELLIS RD	SIOUX FALLS	SD	Active
DSH430027B	Child	DSH	Sanford USD Medical Center	Sanford USD 34th & Kiwanis Family Medicine	2701 S Kiwanis Ave.	Sioux Falls	SD	Active
DSH430027BA	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Developmental	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BB	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - SCSC Hospitalists	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BC	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Critical Care	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BD	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Pulmonology	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BE	Child	DSH	Sanford USD Medical Center	Sanford Childrens MB2 Clinic - Pediatrics	1420 W 22 St	Sioux Falls	SD	Active
DSH430027BF	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Gastroenterology	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BG	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Surgery	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BH	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Urology	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BJ	Child	DSH	Sanford USD Medical Center	Sanford Fertility & Reproductive Medicine - Reproductive Endocrinology	1500 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BK	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Nephrology	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BL	Child	DSH	Sanford USD Medical Center	Edith Sanford Breast Center - Radiology	1210 W. 18th St.	Sioux Falls	SD	Active
DSH430027BM	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - SCSC Infusion	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BN	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Sleep Medicine	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BP	Child	DSH	Sanford USD Medical Center	Sanford Brandon Children's Clinic - Pediatrics	1105 E. Holly Blvd.	Brandon	SD	Active
DSH430027BQ	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Rehabilitation	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BR	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Palliative Care	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BS	Child	DSH	Sanford USD Medical Center	Sanford Breast Health Institute - Bridges - Radiology	5019 S. Western Ave.	Sioux Falls	SD	Active
DSH430027BT	Child	DSH	Sanford USD Medical Center	Sanford Psychiatry & Psychology - Psychiatry and Psychology	2400 W. 49th St.	Sioux Falls	SD	Active
DSH430027BU	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Genetics	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BV	Child	DSH	Sanford USD Medical Center	Sanford Womens Health Ultrasound Diagnostic Center - Radiology	1500 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BW	Child	DSH	Sanford USD Medical Center	Edith Sanford Breast Center - Athena - Radiology	1210 W. 18 St.	Sioux Falls	SD	Terminated
DSH430027BX	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Endocrinology	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BY	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Hematology & Oncology	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027BZ	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - SCSC Neonatology	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027C	Child	DSH	Sanford USD Medical Center	Sanford 32nd & Ellis Clinic	2601 S Ellis Rd.	Sioux Falls	SD	Active
DSH430027CA	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Neurology	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027CB	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Cardiology	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027CC	Child	DSH	Sanford USD Medical Center	Sanford Sports Complex Acute Care and Orthopedic Fast Track - Acute Care	4000 N Brandan Ln	Sioux Falls	SD	Active
DSH430027CD	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Infectious Disease	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027CE	Child	DSH	Sanford USD Medical Center	Sanford Childrens Specialty Clinic - Pediatric Rheumatology	1600 W. 22nd St.	Sioux Falls	SD	Active
DSH430027CF	Child	DSH	Sanford USD Medical Center	Sanford Maternal-Fetal Medicine - Obstetrics	1500 W. 22nd St.	Sioux Falls	SD	Active
DSH430027CG	Child	DSH	Sanford USD Medical Center	Sanford Obstetrics and Gynecology, Womens Health Plaza - Obstetrics and Gynecology	5019 S Western Ave	Sioux Falls	SD	Active
DSH430027CH	Child	DSH	Sanford USD Medical Center	Sanford Renal Dialysis Sioux Falls - Renal Hemodialysis	1321 W. 22nd Street	Sioux Falls	SD	Active
DSH430027CJ	Child	DSH	Sanford USD Medical Center	Sanford Renal Dialysis Madison - Renal Dialysis	323 W. 10th Street	Madison	SD	Active
DSH430027CK	Child	DSH	Sanford USD Medical Center	Sanford Anticoagulation Clinic - Anticoagulation	1420 W 22 St	Sioux Falls	SD	Active
DSH430027CL	Child	DSH	Sanford USD Medical Center	Women's Health 69th & Louise - WOMENS HLTH 69LOUIS SC	6101 S Louise Ave	Sioux Falls	SD	Active
DSH430027CM	Child	DSH	Sanford USD Medical Center	Acute Care Brandon - ACUTE CARE BRANDON SC	1105 E Holly Blvd	Brandon	SD	Active
DSH430027CN	Child	DSH	Sanford USD Medical Center	Women's Health Brandon - WOMENS HLTH BRANDON SC	1105 E Holly Blvd	Brandon	SD	Active
DSH430027CP	Child	DSH	Sanford USD Medical Center	Cardiovascular Inst Vermillion Clinic - Cardiovascular Inst Vermillion Clinic	20 South Plum Street	Vermillion	SD	Terminated
DSH430027CQ	Child	DSH	Sanford USD Medical Center	Cardiovascular Inst Sheldon Clinic - Cardiovascular Inst Sheldon Clinic	800 Oak St.	Sheldon	IA	Terminated
DSH430027CR	Child	DSH	Sanford USD Medical Center	Weight Management - Weight Management	1310 W. 22nd St. Talley Building Lower Level	Sioux Falls	SD	Active
DSH430027CS	Child	DSH	Sanford USD Medical Center	Cardiovascular Inst Chamberlain Clinic - Cardiovascular Inst Chamberlain Clinic	300 S. Byron Blvd.	Chamberlain	SD	Terminated
DSH430027CT	Child	DSH	Sanford USD Medical Center	Cardiovascular Inst Jackson Clinic - Cardiovascular Inst Jackson Clinic	1430 N. Highway	Jackson	MN	Terminated
DSH430027CU	Child	DSH	Sanford USD Medical Center	Nephrology Mitchell Clinic - Nephrology Mitchell Clinic	2100 Highland Way Suite K	Mitchell	SD	Terminated
DSH430027CV	Child	DSH	Sanford USD Medical Center	Cardiovascular Inst Windom Clinic - Cardiovascular Inst Windom Clinic	591 2nd Ave N	Windom	MN	Terminated
DSH430027CW	Child	DSH	Sanford USD Medical Center	Womens Health Brookings Clinic - Womens Health Brookings Clinic	922 22nd Ave. S.	Brookings	SD	Terminated
DSH430027CX	Child	DSH	Sanford USD Medical Center	Cardiovascular Inst Watertown Clinic - Cardiovascular Inst Watertown Clinic	901 Fourth St. NW	Watertown	SD	Terminated
DSH430027CY	Child	DSH	Sanford USD Medical Center	Sanford Hartford Clinic - Hartford Clinic	905 N Oaks Ave	Hartford	SD	Active
DSH430027CZ	Child	DSH	Sanford USD Medical Center	Sanford Harrisburg Childrens - Childrens Harrisburg	111 N Cliff Ave	Harrisburg	SD	Active
DSH430027D	Child	DSH	Sanford USD Medical Center	Sanford 49th and Oxbow Family Medicine	3401 W 49th Street	Sioux Falls	SD	Active
DSH430027DA	Child	DSH	Sanford USD Medical Center	Sanford Harrisburg Clinic - Sanford Harrisburg Clinic	111 N Cliff Ave	Harrisburg	SD	Active
DSH430027DB	Child	DSH	Sanford USD Medical Center	Sanford Womens Health Harrisburg - Womens Health Harrisburg	111 N Cliff Ave	Harrisburg	SD	Active
DSH430027DC	Child	DSH	Sanford USD Medical Center	SANFORD CLINIC WOMEN'S INTEGRATIVE HEALTH - SANFORD CLINIC WOMEN'S INTEGRATIVE HEALTH	5019 S WESTERN AVE STE 200	SIOUX FALLS	SD	Active
DSH430027DD	Child	DSH	Sanford USD Medical Center	WOMENS HEALTH MADISON - WOMENS HEALTH MADISON	323 10TH ST SW	MADISON	SD	Terminated
DSH430027DE	Child	DSH	Sanford USD Medical Center	VASCULAR ASSOCIATES VERMILLION - VASCULAR ASSOCIATES VERMILLION	20 S PLUM ST	VERMILLION	SD	Terminated
DSH430027DF	Child	DSH	Sanford USD Medical Center	PULMONOLOGY CHAMBERLAIN - PULMONOLOGY CHAMBERLAIN	300 S BYRON BLVD	CHAMBERLAIN	SD	Terminated
DSH430027DG	Child	DSH	Sanford USD Medical Center	NEPHROLOGY VERMILLION - NEPHROLOGY VERMILLION	20 S PLUM ST	VERMILLION	SD	Terminated
DSH430027DH	Child	DSH	Sanford USD Medical Center	PULMONOLOGY WINDOM - PULMONOLOGY WINDOM	2150 HOSPITAL DR	WINDOM	MN	Terminated
DSH430027DJ	Child	DSH	Sanford USD Medical Center	NEUROLOGY MITCHELL - NEUROLOGY MITCHELL	2100 HIGHLAND WAY SUITE K	MITCHELL	SD	Terminated
DSH430027DK	Child	DSH	Sanford USD Medical Center	PULMONOLOGY VERMILLION - PULMONOLOGY VERMILLION	20 S PLUM ST	VERMILLION	SD	Terminated
DSH430027DL	Child	DSH	Sanford USD Medical Center	NEPHROLOGY MID DAK - NEPHROLOGY MID DAK	300 S BYRON BLVD	CHAMBERLAIN	SD	Terminated
DSH430027DM	Child	DSH	Sanford USD Medical Center	VASCULAR ASSOCIATES SHELDON - VASCULAR ASSOCIATES SHELDON	800 OAK ST	SHELDON	IA	Terminated
DSH430027DN	Child	DSH	Sanford USD Medical Center	NEUROLOGY VERMILLION - NEUROLOGY VERMILLION	20 S PLUM ST	VERMILLION	SD	Terminated
DSH430027DP	Child	DSH	Sanford USD Medical Center	NEPHROLOGY CANBY - NEPHROLOGY CANBY	112 SAINT OLAF AVE S	CANBY	MN	Terminated
DSH430027DQ	Child	DSH	Sanford USD Medical Center	VASCULAR ASSOCIATES CHAMBERLAIN - VASCULAR ASSOCIATES CHAMBERLAIN	300 S BYRON BLVD	CHAMBERLAIN	SD	Terminated
DSH430027DR	Child	DSH	Sanford USD Medical Center	VASCULAR ASSOCIATE JACKSON - VASCULAR ASSOCIATE JACKSON	1430 N HWY	JACKSON	MN	Terminated
DSH430027DS	Child	DSH	Sanford USD Medical Center	SANFORD CARDIOVASCULAR INSTITUTE CLEAR LAKE - SANFORD CARDIOVASCULAR INSTITUTE CLEAR LAKE	701 S 3RD AVE	CLEAR LAKE	SD	Terminated
DSH430027DT	Child	DSH	Sanford USD Medical Center	Sanford Canistota Family Medicine - Sanford Canistota Family Medicine	320 W MAIN ST	Canistota	SD	Active
DSH430027DU	Child	DSH	Sanford USD Medical Center	Vascular Associates Watertown - Vascular Associates Watertown	901 4TH ST NW	Watertown	SD	Active
DSH430027DV	Child	DSH	Sanford USD Medical Center	Pulmonology Sheldon - Pulmonology Sheldon	118 N 7TH AVE	Sheldon	IA	Active
DSH430027DW	Child	DSH	Sanford USD Medical Center	Cardiovascular Inst Webster Clinic - Cardiovascular Inst Webster Clinic	1401 W 1ST ST	Webster	SD	Active
DSH430027DX	Child	DSH	Sanford USD Medical Center	Pulmonology Watertown - Pulmonology Watertown	901 4TH ST NW	Watertown	SD	Active
DSH430027DY	Child	DSH	Sanford USD Medical Center	Sanford Psychiatry & Psychology Louise Clinic - Sanford Psychiatry & Psychology Louise Clinic	7511 S Louise	Sioux Falls	SD	Active
DSH430027DZ	Child	DSH	Sanford USD Medical Center	Sanford Childrens Clinic Stress Lab - Sanford Childrens Clinic Stress Lab	1600 W 22nd St	Sioux Falls	SD	Active
DSH430027E	Child	DSH	Sanford USD Medical Center	Sanford 4th and Sycamore Family Medicine	600 N. Sycamore Ave.	Sioux Falls	SD	Active
DSH430027EA	Child	DSH	Sanford USD Medical Center	Rock Rapids Clinic Therapy - Rock Rapids Clinic Therapy	104 Buncombe Dr	Rock Rapids	IA	Active
DSH430027EB	Child	DSH	Sanford USD Medical Center	Rock Rapids Clinic Radiology - Rock Rapids Clinic Radiology	104 Buncombe Dr	Rock Rapids	IA	Active
DSH430027EC	Child	DSH	Sanford USD Medical Center	Rock Rapids Clinic Nursing Procedure - Rock Rapids Clinic Nursing Procedure	104 Buncombe Dr	Rock Rapids	IA	Active
DSH430027ED	Child	DSH	Sanford USD Medical Center	Rock Rapids Clinic - Rock Rapids Clinic	104 Buncombe Dr	Rock Rapids	IA	Active
DSH430027EE	Child	DSH	Sanford USD Medical Center	Sanford Childrens Clinic Lifescape Outreach - Sanford Childrens Clinic Lifescape Outreach	1020 W 18th St	Sioux Falls	SD	Active
DSH430027EF	Child	DSH	Sanford USD Medical Center	Sanford Radiation Oncology Clinic - Sanford Radiation Oncology Clinic	1309 W 17th St	Sioux Falls	SD	Active
DSH430027EG	Child	DSH	Sanford USD Medical Center	Nuc Med Cancer Ctr SMC - Nuc Med Cancer Ctr SMC	1309 W 17th St	Sioux Falls	SD	Active
DSH430027EH	Child	DSH	Sanford USD Medical Center	Nuc Med HH SMC - Nuc Med HH SMC	1301 W 18th St	Sioux Falls	SD	Active
DSH430027EJ	Child	DSH	Sanford USD Medical Center	SANFORD OUTPATIENT CARE CENTER - SANFORD OUTPATIENT CARE CENTER	1305 W 18TH ST	SIOUX FALLS	SD	Active
DSH430027F	Child	DSH	Sanford USD Medical Center	Sanford 69th and Minnesota Family Medicine	6110 S. Minnesota Avenue	Sioux Falls	SD	Active
DSH430027G	Child	DSH	Sanford USD Medical Center	Sanford Internal Medicine Clinic	1321 W. 22nd St.	Sioux Falls	SD	Active
DSH430027H	Child	DSH	Sanford USD Medical Center	Sanford Brandon Family Medicine	1105 E Holly Blvd	Brandon	SD	Active
DSH430027J	Child	DSH	Sanford USD Medical Center	Sanford Center for Digestive Health	1211 S Grange Ave	Sioux Falls	SD	Active
DSH430027K	Child	DSH	Sanford USD Medical Center	Sanford Dermatology Clinic	1310 W 22nd Street	Sioux Falls	SD	Active
DSH430027L	Child	DSH	Sanford USD Medical Center	Sanford Diabetes and Thyroid Clinic	1305 W 18th Street	Sioux Falls	SD	Active
DSH430027M	Child	DSH	Sanford USD Medical Center	Sanford Eye Center and Optical	1621 S. Minnesota Avenue	Sioux Falls	SD	Active
DSH430027N	Child	DSH	Sanford USD Medical Center	Sanford Female Pelvic Medicine and Reconstructive Surgery Clinic	1500 W 22nd Street	Sioux Falls	SD	Active
DSH430027P	Child	DSH	Sanford USD Medical Center	Sanford Gynecologic Oncology Clinic	1309 W 17th St.	Sioux Falls	SD	Active
DSH430027Q	Child	DSH	Sanford USD Medical Center	Sanford Nephrology Clinic	1420 W 22 St	Sioux Falls	SD	Active
DSH430027R	Child	DSH	Sanford USD Medical Center	Sanford Neurology Clinic	1210 W 18th Street	Sioux Falls	SD	Active
DSH430027S	Child	DSH	Sanford USD Medical Center	Sanford Neurosurgery and Spine Clinic	1210 W 18th Street	Sioux Falls	SD	Active
DSH430027T	Child	DSH	Sanford USD Medical Center	Sanford Obstetrics and Gynecology Clinic	1500 W 22nd Street	Sioux Falls	SD	Active
DSH430027U	Child	DSH	Sanford USD Medical Center	Sanford Physical Medicine and Rehabilitation Clinic	1210 W 18th Street	Sioux Falls	SD	Active
DSH430027V	Child	DSH	Sanford USD Medical Center	Sanford Pulmonary Medicine Clinic	1420 W 22 St	Sioux Falls	SD	Active
DSH430027W	Child	DSH	Sanford USD Medical Center	Sanford Rheumatology Clinic	1321 W. 22nd St Sanford Imagenetics	Sioux Falls	SD	Active
DSH430027X	Child	DSH	Sanford USD Medical Center	Sanford Surgical Associates	1508 West 22nd Street	Sioux Falls	SD	Active
DSH430027Y	Child	DSH	Sanford USD Medical Center	Sanford Vascular Associates	1305 W 18th Street	Sioux Falls	SD	Active
DSH430027Z	Child	DSH	Sanford USD Medical Center	Sanford Women's Internal Medicine Clinic	5019 S Western Avenue	Sioux Falls	SD	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Vanden Hull, Eric Lucas Vice President of Finance - Sioux Falls HSD Sanford Health 7122615275	7/18/2024 8:28 AM
Details	340B ID	Update	New Registration		DSH430027ED	7/18/2024 8:28 AM
Details	Entity Subname	Update	New Registration	Rock Rapids Clinic	Rock Rapids Clinic - Rock Rapids Clinic	7/18/2024 8:28 AM
Dates	Participating Approval Date	Update	New Registration		7/18/2024 8:28:20 AM	7/18/2024 8:28 AM
Details	State	Update	New Registration	Pending	Approved	7/18/2024 8:28 AM
Dates	Signed By Date	Update	New Registration		7/14/2024 9:33:36 PM	7/18/2024 8:28 AM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	7/18/2024 8:28 AM
Addresses	Main Address	Insert	New Registration		104 Buncombe Dr Rock Rapids, IA 51246-1003	7/12/2024 2:46 PM
Addresses	Billing Address	Insert	New Registration		Sanford USD Medical Center 1305 W 18th St Sioux Falls, SD 57117-5039	7/12/2024 2:46 PM
Addresses	Shipping Address	Insert	New Registration		Sanford USD Medical Center 1305 W 18th St Sioux Falls, SD 57117-5039	7/12/2024 2:46 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972844793	7/12/2024 2:46 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/12/2024 2:46 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093090342	7/12/2024 2:46 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/12/2024 2:46 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1821017880	7/12/2024 2:46 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/12/2024 2:46 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972844793	7/12/2024 2:46 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	7/12/2024 2:46 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972844793	7/12/2024 2:46 PM
Medicaid Billing	NPI: State	Insert	New Registration		NE	7/12/2024 2:46 PM
Contacts	Primary Contact	Insert	New Registration		Howard, Alyssa O Director of Pharmacy Sanford USD Medical Center 6056951697	7/12/2024 2:46 PM
Contacts	Authorizing Official	Insert	New Registration		Vanden Hull, Eric Lucas Vice President of Finance - Sioux Falls HSD Sanford Health 7122615275	7/12/2024 2:46 PM
Details	Assistance Received From Date	Insert	New Registration			7/12/2024 2:46 PM
Details	Assistance Received To Date	Insert	New Registration			7/12/2024 2:46 PM
Details	Last Recertification Date	Insert	New Registration			7/12/2024 2:46 PM
Details	Grant Number	Insert	New Registration			7/12/2024 2:46 PM
Details	340B ID	Insert	New Registration			7/12/2024 2:46 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/12/2024 2:46 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/12/2024 2:46 PM
Details	Medicare Provider Number	Insert	New Registration		430027	7/12/2024 2:46 PM
Details	Entity Name	Insert	New Registration		Sanford USD Medical Center	7/12/2024 2:46 PM
Details	NOFO Number	Insert	New Registration			7/12/2024 2:46 PM
Details	Program Code	Insert	New Registration		DSH	7/12/2024 2:46 PM
Details	Entity Subname	Insert	New Registration		Rock Rapids Clinic	7/12/2024 2:46 PM
Dates	Participating Approval Date	Insert	New Registration			7/12/2024 2:46 PM
Details	State	Insert	New Registration		Pending	7/12/2024 2:46 PM
Dates	Registration Date	Insert	New Registration		7/12/2024 2:46:30 PM	7/12/2024 2:46 PM
Dates	Signed By Date	Insert	New Registration			7/12/2024 2:46 PM
Dates	Start Date	Insert	New Registration			7/12/2024 2:46 PM
Terminations	Termination Comments	Insert	New Registration			7/12/2024 2:46 PM
Terminations	Termination Date	Insert	New Registration			7/12/2024 2:46 PM
Terminations	Termination Effective Date	Insert	New Registration			7/12/2024 2:46 PM
Terminations	Termination Reason	Insert	New Registration			7/12/2024 2:46 PM