Covered Entity Details

RRC240210-02 HEALTHEAST ST JOHNS HOSPITAL (Approved) - information as of 5/11/2025 11:30:45 PM

Main Details

Name

HEALTHEAST ST JOHNS HOSPITAL

Subdivision Name

Pain Center - Pain Center

Type

Rural Referral Center

Rural

340B ID

RRC240210-02

Medicare Provider Number

240210

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/11/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/16/2025

Last Recertification Date

Contacts

Authorizing Official

Fairview Health Services
Trudi Noel Trysla, Chief Legal Officer
(612) 672-6382

Primary Contact

HealthEast Care System
Dean Huska, Director - Pharmacy Contracting
(651) 324-9440

Addresses

Street Address

1600 St. John's Blvd
Maplewood, MN 55109

Billing Address

HealthEast St. John's Hospital
1575 Beam Avenue
Maplewood, MN 55109

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	410852300,514179601	1447218482

Shipping Addresses

Shipping Address 1

HealthEast St. John's Hospital
1575 Beam Avenue
Maplewood, MN 55109

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
RRC240210-01	Child	RRC	HEALTHEAST ST JOHNS HOSPITAL	Medication Management Clinic - Medication Therapy Management	1600 St. John's Blvd	Maplewood	MN	Approved
RRC240210-02	Child	RRC	HEALTHEAST ST JOHNS HOSPITAL	Pain Center - Pain Center	1600 St. John's Blvd	Maplewood	MN	Approved
RRC240210-03	Child	RRC	HEALTHEAST ST JOHNS HOSPITAL	Fairview Cancer Infusion Woodbury - Infusion Therapy	1875 Woodwinds Drive	Woodbury	MN	Approved
RRC240210-04	Child	RRC	HEALTHEAST ST JOHNS HOSPITAL	HealthEast Vascular Center Maplewood - Vascular Center	2945 Hazelwood Street	Maplewood	MN	Approved
RRC240210-05	Child	RRC	HEALTHEAST ST JOHNS HOSPITAL	Fairview Cancer Center Woodbury - Oncology	1875 Woodwinds Drive	Woodbury	MN	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Trysla, Trudi Noel Chief Legal Officer Fairview Health Services 6126726382	4/16/2025 2:53 PM
Details	340B ID	Update	New Registration		RRC240210-02	4/16/2025 2:53 PM
Details	Entity Subname	Update	New Registration	Pain Center	Pain Center - Pain Center	4/16/2025 2:53 PM
Dates	Participating Approval Date	Update	New Registration		4/16/2025 2:53:47 PM	4/16/2025 2:53 PM
Details	State	Update	New Registration	Pending	Approved	4/16/2025 2:53 PM
Dates	Signed By Date	Update	New Registration		4/15/2025 11:24:53 AM	4/16/2025 2:53 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/16/2025 2:53 PM
Addresses	Billing Address	Insert	New Registration		HealthEast St. John's Hospital 1575 Beam Avenue Maplewood, MN 55109	4/15/2025 11:24 AM
Addresses	Shipping Address	Insert	New Registration		HealthEast St. John's Hospital 1575 Beam Avenue Maplewood, MN 55109	4/15/2025 11:24 AM
Addresses	Main Address	Insert	New Registration		1600 St. John's Blvd Maplewood, MN 55109	4/11/2025 11:33 AM
Addresses	Billing Address	Insert	New Registration		HealthEast St. John's Hospital 1575 Beam Avenue Maplewood, MN 55109	4/11/2025 11:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:33 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		410852300	4/11/2025 11:33 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	4/11/2025 11:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:33 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		514179601	4/11/2025 11:33 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	4/11/2025 11:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1447218482	4/11/2025 11:33 AM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/11/2025 11:33 AM
Contacts	Authorizing Official	Insert	New Registration		Trysla, Trudi Noel Chief Legal Officer Fairview Health Services 6126726382	4/11/2025 11:33 AM
Contacts	Primary Contact	Insert	New Registration		Huska, Dean Director - Pharmacy Contracting HealthEast Care System 6513249440	4/11/2025 11:33 AM
Details	Assistance Received From Date	Insert	New Registration			4/11/2025 11:33 AM
Details	Assistance Received To Date	Insert	New Registration			4/11/2025 11:33 AM
Details	Last Recertification Date	Insert	New Registration			4/11/2025 11:33 AM
Details	Grant Number	Insert	New Registration			4/11/2025 11:33 AM
Details	340B ID	Insert	New Registration			4/11/2025 11:33 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/11/2025 11:33 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/11/2025 11:33 AM
Details	Medicare Provider Number	Insert	New Registration		240210	4/11/2025 11:33 AM
Details	Entity Name	Insert	New Registration		HEALTHEAST ST JOHNS HOSPITAL	4/11/2025 11:33 AM
Details	NOFO Number	Insert	New Registration			4/11/2025 11:33 AM
Details	Program Code	Insert	New Registration		RRC	4/11/2025 11:33 AM
Details	Entity Subname	Insert	New Registration		Pain Center	4/11/2025 11:33 AM
Dates	Participating Approval Date	Insert	New Registration			4/11/2025 11:33 AM
Details	State	Insert	New Registration		Pending	4/11/2025 11:33 AM
Dates	Registration Date	Insert	New Registration		4/11/2025 11:33:14 AM	4/11/2025 11:33 AM
Dates	Signed By Date	Insert	New Registration			4/11/2025 11:33 AM
Dates	Start Date	Insert	New Registration			4/11/2025 11:33 AM
Terminations	Termination Comments	Insert	New Registration			4/11/2025 11:33 AM
Terminations	Termination Date	Insert	New Registration			4/11/2025 11:33 AM
Terminations	Termination Effective Date	Insert	New Registration			4/11/2025 11:33 AM
Terminations	Termination Reason	Insert	New Registration			4/11/2025 11:33 AM