Covered Entity Details

SCH350019-08 ALTRU HOSPITAL (Terminated) - information as of 4/25/2025 8:34:38 PM

Main Details

Name

ALTRU HOSPITAL

Subdivision Name

ALTRU CLINIC - CROOKSTON

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH350019-08

Medicare Provider Number

350019

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

8/4/2010

Participating Start Date

8/5/2010

Participating Approval Date

8/4/2010

Last Recertification Date

8/27/2018

Termination Date
Termination Reason

1/1/2019
Other

Contacts

Authorizing Official

Altru Health System
Janice Hamscher, Chief Nursing Officer
(701) 780-3403

Primary Contact

Altru Health System
Cherri Ellis, Supervisor, Budgeting & Cost Accounting
(701) 780-5724

Addresses

Street Address

400 S.MINNESOTA STREET
CROOKSTON, MN 56716

Billing Address

ALTRU HOSPITAL
PO BOX 13780
GRAND FORKS, ND 58208-3780

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?
No

Shipping Addresses

Same as Street Address

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
SCH350019-01	Child	SCH	ALTRU HOSPITAL	ALTRU CANCER CENTER	960 S.COLUMBIA ROAD	GRAND FORKS	ND	Terminated
SCH350019-02	Child	SCH	ALTRU HOSPITAL	Altru 860 Columbia	860 S. COLUMBIA ROAD	GRAND FORKS	ND	Terminated
SCH350019-03	Child	SCH	ALTRU HOSPITAL	ALTRU FAMILY MEDICINE CENTER	1380 S.COLUMBIA ROAD	GRAND FORKS	ND	Terminated
SCH350019-04	Child	SCH	ALTRU HOSPITAL	ALTRU MAIN CLINIC	1000 S.COLUMBIA ROAD	GRAND FORKS	ND	Terminated
SCH350019-05	Child	SCH	ALTRU HOSPITAL	ALTRU FAMILY MEDICINE RESIDENCY	725 HAMLINE STREET	GRAND FORKS	ND	Terminated
SCH350019-06	Child	SCH	ALTRU HOSPITAL	TRUYU AESTHETIC CENTER	3165 DEMERS AVE.	GRAND FORKS	ND	Terminated
SCH350019-07	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia	1300 S. COLUMBIA ROAD	GRAND FORKS	ND	Terminated
SCH350019-08	Child	SCH	ALTRU HOSPITAL	ALTRU CLINIC - CROOKSTON	400 S.MINNESOTA STREET	CROOKSTON	MN	Terminated
SCH350019-10	Child	SCH	ALTRU HOSPITAL	Altru Professional Center	4440 S Washington St	Grand Forks	ND	Terminated
SCH350019-100	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Breast Center	4440 S Washington St	Grand Forks	ND	Active
SCH350019-101	Child	SCH	ALTRU HOSPITAL	Devils Lake - Orthopedics	1001 7th St NE	Devils Lake	ND	Active
SCH350019-102	Child	SCH	ALTRU HOSPITAL	Devils Lake - Urology	1001 7th St NE	Devils Lake	ND	Active
SCH350019-103	Child	SCH	ALTRU HOSPITAL	Family Medicine Center - Pediatric NICU Developmental Clinic	1375 S Columbia Rd	Grand Forks	ND	Active
SCH350019-104	Child	SCH	ALTRU HOSPITAL	Devils Lake - Vascular Surgery	1001 7th St NE	Devils Lake	ND	Active
SCH350019-105	Child	SCH	ALTRU HOSPITAL	Crookston - Podiatry	400 S Minnesota St	Crookston	MN	Active
SCH350019-106	Child	SCH	ALTRU HOSPITAL	Devils Lake - General Surgery	1001 7th St NE	Devils Lake	ND	Active
SCH350019-107	Child	SCH	ALTRU HOSPITAL	Altru Specialty Center - Ultrasound	4440 S Washington St	Grand Forks	ND	Active
SCH350019-108	Child	SCH	ALTRU HOSPITAL	Altru Health System - Vascular Ultrasound	1300 S Columbia Rd	Grand Forks	ND	Active
SCH350019-109	Child	SCH	ALTRU HOSPITAL	Altru Specialty Center - APC Orthopedic Xray	4440 S Washington St	Grand Forks	ND	Active
SCH350019-11	Child	SCH	ALTRU HOSPITAL	Altru Specialty Center - First Floor	4500 S Washington St	Grand Forks	ND	Active
SCH350019-110	Child	SCH	ALTRU HOSPITAL	Altru Health System - FMR Diagnostic Radiology	725 Hamline St	Grand Forks	ND	Active
SCH350019-111	Child	SCH	ALTRU HOSPITAL	Altru Specialty Center - Diagnostic Radiology	4440 S Washington St	Grand Forks	ND	Active
SCH350019-112	Child	SCH	ALTRU HOSPITAL	Crookston - Radiology	400 S Minnesota St	Crookston	MN	Active
SCH350019-113	Child	SCH	ALTRU HOSPITAL	Altru 1300 Colombia - Radiology- Diagnostic	1300 S Columbia Rd	Grand Forks	ND	Active
SCH350019-114	Child	SCH	ALTRU HOSPITAL	Altru Health System - Mammography	4440 S Washington St	Grand Forks	ND	Active
SCH350019-115	Child	SCH	ALTRU HOSPITAL	Altru Health System - FMC Diagnostic Radiology	1380 S Columbia Rd	Grand Forks	ND	Active
SCH350019-116	Child	SCH	ALTRU HOSPITAL	Crookston - Cardiology Echo	400 S Minnesota St	Crookston	MN	Active
SCH350019-117	Child	SCH	ALTRU HOSPITAL	Altru Cancer Center - PET Scan	960 S Columbia Rd	Grand Forks	ND	Active
SCH350019-119	Child	SCH	ALTRU HOSPITAL	Devils Lake - Primary Care	1001 7th St NE	Devils Lake	ND	Active
SCH350019-12	Child	SCH	ALTRU HOSPITAL	Truyu at Choice	4401 S 11th St	Grand Forks	ND	Terminated
SCH350019-13	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Altru Eye Department/Ophthalmology	4440 S. Washington St.	Grand Forks	ND	Active
SCH350019-14	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia - OB/GYN	1300 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-15	Child	SCH	ALTRU HOSPITAL	Altru Clinic East Grand Forks - Family Medicine	607 DeMers Avenue	East Grand Forks	MN	Active
SCH350019-16	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Residency - Family Medicine	725 Hamline St	Grand Forks	ND	Active
SCH350019-17	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia - Neurology	1300 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-18	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Center - Infectious Disease	1380 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-19	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Center - Allergy	1380 S. Columbia Rd.	Grand Forks	ND	Terminated
SCH350019-20	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia - Vascular Medicine/Chronic Wound Clinic	1300 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-21	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia - Pulmonology	1300 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-22	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia - Physiatry/Physical Medicine/Rehab	1300 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-23	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Family Medicine South	4440 S. Washington St.	Grand Forks	ND	Active
SCH350019-24	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Ear, Nose, and Throat	4440 S. Washington St.	Grand Forks	ND	Active
SCH350019-25	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Infusion Services	400 South Minnesota St.	Crookston	MN	Active
SCH350019-26	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Family Medicine	400 South Minnesota St.	Crookston	MN	Active
SCH350019-27	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Urology	4440 S. Washington St.	Grand Forks	ND	Active
SCH350019-28	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Gastroenterology	4440 S. Washington Street	Grand Forks	ND	Active
SCH350019-29	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Center - Pediatrics	1380 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-30	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Altru Advanced Orthopedics	4440 S. Washington St.	Grand Forks	ND	Active
SCH350019-31	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia - Nephrology	1300 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-32	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia - Cardiovascular Thoracic Surgery	1300 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-33	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Endoscopy/Procedural Services	4440 S. Washington St.	Grand Forks	ND	Active
SCH350019-34	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Renal Dialysis	400 South Minnesota St.	Crookston	MN	Active
SCH350019-35	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Center - Family Medicine	1380 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-36	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Neurology	400 South Minnesota St.	Crookston	MN	Terminated
SCH350019-37	Child	SCH	ALTRU HOSPITAL	Altru Clinic East Grand Forks - Dermatology	607 DeMers Avenue	East Grand Forks	MN	Terminated
SCH350019-38	Child	SCH	ALTRU HOSPITAL	Altru Clinic East Grand Forks - Family Medicine Residency	607 DeMers Avenue	East Grand Forks	MN	Terminated
SCH350019-39	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Dermatology	400 South Minnesota St.	Crookston	MN	Active
SCH350019-40	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Center - Rheumatology	1380 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-41	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Urology	400 South Minnesota St.	Crookston	MN	Active
SCH350019-42	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Center - Pediatric Medical Home	1380 S. Columbia Rd.	Grand Forks	ND	Terminated
SCH350019-43	Child	SCH	ALTRU HOSPITAL	Altru Specialty Center - Surgery	4500 S Washington St	Grand Forks	ND	Active
SCH350019-44	Child	SCH	ALTRU HOSPITAL	Altru 860 Columbia Clinic - Occupational Medicine	860 S Columbia Rd	Grand Forks	ND	Active
SCH350019-45	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia Clinic - Neurosurgery	1300 S Columbia Rd	Grand Forks	ND	Active
SCH350019-46	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Center - Diabetic Education	1380 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-47	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Podiatry	4440 S. Washington St.	Grand Forks	ND	Active
SCH350019-48	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Cardiology	400 South Minnesota St.	Crookston	MN	Active
SCH350019-49	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Oncology	400 South Minnesota St.	Crookston	MN	Active
SCH350019-50	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Vascular/General Surgery	400 South Minnesota St.	Crookston	MN	Active
SCH350019-51	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Center - Internal Medicine	1380 S. Columbia Rd.	Grand Forks	ND	Active
SCH350019-52	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Center - Medical Home	1380 S. Columbia Rd.	Grand Forks	ND	Terminated
SCH350019-53	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Center - Internal Medicine Medical Home	1380 S. Columbia Rd.	Grand Forks	ND	Terminated
SCH350019-54	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia Clinic - Cardiology Echo	1300 S Columbia Rd	Grand Forks	ND	Active
SCH350019-55	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Pain Management	4440 S. Washington St.	Grand Forks	ND	Active
SCH350019-56	Child	SCH	ALTRU HOSPITAL	Truyu Anesthetic Center - Plastic Surgery	3165 Demers Ave	Grand Forks	ND	Active
SCH350019-57	Child	SCH	ALTRU HOSPITAL	Altru Cancer Center - Cancer Center Infusion Center	960 S Columbia Rd	Grand Forks	ND	Active
SCH350019-58	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia Clinic - Cardiology	1300 S Columbia Rd	Grand Forks	ND	Active
SCH350019-59	Child	SCH	ALTRU HOSPITAL	Altru Family Medicine Residency - Diet/Diabetic Education	725 Hamline St	Grand Forks	ND	Active
SCH350019-60	Child	SCH	ALTRU HOSPITAL	Altru 860 Columbia Clinic - Behavioral Health Services	860 S Columbia Rd	Grand Forks	ND	Active
SCH350019-61	Child	SCH	ALTRU HOSPITAL	Altru Cancer Center - Oncology	960 S Columbia Rd	Grand Forks	ND	Active
SCH350019-62	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Express Family Medicine South Clinic	4440 S. Washington St.	Grand Forks	ND	Active
SCH350019-63	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Pediatrics	400 South Minnesota St.	Crookston	MN	Active
SCH350019-64	Child	SCH	ALTRU HOSPITAL	Altru Cancer Center - Radiation Oncology	960 S Columbia Rd	Grand Forks	ND	Active
SCH350019-65	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Family Medicine Health Coach/Medical Home	4440 S. Washington St.	Grand Forks	ND	Terminated
SCH350019-66	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Ear, Nose, and Throat	400 South Minnesota St.	Crookston	MN	Active
SCH350019-67	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Obstetrics and Gynecology	400 South Minnesota St.	Crookston	MN	Active
SCH350019-68	Child	SCH	ALTRU HOSPITAL	Altru Clinic East Grand Forks - Medical Home	607 DeMers Avenue	East Grand Forks	MN	Terminated
SCH350019-69	Child	SCH	ALTRU HOSPITAL	Altru Specialty Center - MRI	4500 S Washington St	Grand Forks	ND	Active
SCH350019-70	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia Clinic - Vascular Surgery	1300 S Columbia Rd	Grand Forks	ND	Active
SCH350019-71	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Diabetes Center	400 South Minnesota St.	Crookston	MN	Active
SCH350019-72	Child	SCH	ALTRU HOSPITAL	Altru Specialty Center - CT Medical Imaging	4500 S Washington St	Grand Forks	ND	Active
SCH350019-73	Child	SCH	ALTRU HOSPITAL	Altru Professional Center - Outpatient Procedural Services	4440 S Washington St	Grand Forks	ND	Active
SCH350019-74	Child	SCH	ALTRU HOSPITAL	Altru Clinic Crookston - Anticoagulation Clinic	400 South Minnesota St.	Crookston	MN	Active
SCH350019-75	Child	SCH	ALTRU HOSPITAL	Altru Specialty Center - Pain Management	4500 S Washington St	Grand Forks	ND	Active
SCH350019-76	Child	SCH	ALTRU HOSPITAL	Altru Cancer Center - Palliative Care	960 S Columbia Rd	Grand Forks	ND	Active
SCH350019-77	Child	SCH	ALTRU HOSPITAL	TRUYU AESTHETIC CENTER - Dermatology	3165 Demers Ave	Grand Forks	ND	Active
SCH350019-78	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia Clinic - General Surgery	1300 S Columbia Rd	Grand Forks	ND	Active
SCH350019-79	Child	SCH	ALTRU HOSPITAL	Altru 1300 Columbia Clinic - Electrophysiology	1300 S Columbia Rd	Grand Forks	ND	Active
SCH350019-80	Child	SCH	ALTRU HOSPITAL	East Grand Forks - Express Family Medicine Walk-In/Urgent Care	607 DeMers Avenue	East Grand Forks	MN	Active
SCH350019-81	Child	SCH	ALTRU HOSPITAL	Devils Lake - Ear, Nose, and Throat	1001 7th St NE	Devils Lake	ND	Active
SCH350019-82	Child	SCH	ALTRU HOSPITAL	Center for Prev & Genetics - Orthopedics	4401 S 11th	Grand Forks	ND	Active
SCH350019-83	Child	SCH	ALTRU HOSPITAL	Devils Lake - Nephrology	1001 7th St NE	Devils Lake	ND	Active
SCH350019-84	Child	SCH	ALTRU HOSPITAL	Crookston - Occupational Medicine	400 S Minnesota St	Crookston	MN	Active
SCH350019-85	Child	SCH	ALTRU HOSPITAL	Devils Lake - Dermatology	1001 7th St NE	Devils Lake	ND	Active
SCH350019-86	Child	SCH	ALTRU HOSPITAL	Devils Lake - OB/GYN	1001 7th St NE	Devils Lake	ND	Active
SCH350019-87	Child	SCH	ALTRU HOSPITAL	Thief River Falls - Cardiology	1845 Hwy 59 S	Thief River Falls	MN	Active
SCH350019-88	Child	SCH	ALTRU HOSPITAL	Crookston - Nephrology	400 S Minnesota St	Crookston	MN	Active
SCH350019-89	Child	SCH	ALTRU HOSPITAL	Thief River Falls - Neurology	1845 Hwy 59 S	Thief River Falls	MN	Active
SCH350019-90	Child	SCH	ALTRU HOSPITAL	Erskine - Neurology	23076 347th St SE	Erskine	MN	Active
SCH350019-91	Child	SCH	ALTRU HOSPITAL	Devils Lake - Pain Management	1001 7th St NE	Devils Lake	ND	Terminated
SCH350019-92	Child	SCH	ALTRU HOSPITAL	Devils Lake - Cardiology	1001 7th St NE	Devils Lake	ND	Active
SCH350019-93	Child	SCH	ALTRU HOSPITAL	Thief River Falls - Dermatology	1845 Hwy 59 S	Thief River Falls	MN	Active
SCH350019-94	Child	SCH	ALTRU HOSPITAL	Thief River Falls - Primary Care	1845 Hwy 59 S	Thief River Falls	MN	Active
SCH350019-95	Child	SCH	ALTRU HOSPITAL	Thief River Falls - Outpatient Behavioral Health	1845 Hwy 59 South	Thief River Falls	MN	Active
SCH350019-96	Child	SCH	ALTRU HOSPITAL	Erskine - Primary Care	23076 347th St SE	Erskine	MN	Active
SCH350019-97	Child	SCH	ALTRU HOSPITAL	Crookston - Orthopedics	400 S Minnesota St	Crookston	MN	Active
SCH350019-98	Child	SCH	ALTRU HOSPITAL	Devils Lake - Pediatrics	1001 7th St NE	Devils Lake	ND	Active
SCH350019-99	Child	SCH	ALTRU HOSPITAL	Thief River Falls - Urology	1845 Hwy 59 S	Thief River Falls	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	AO Change Request	Lusignan, Sara Jane Chief Financial Officer Altru Health System 7017805203	Hamscher, Janice Chief Nursing Officer Altru Health System 7017803403	7/9/2020 3:56 PM
Contacts	Authorizing Official	Update	Change Request	Hamscher, Janice Chief Nursing Officer Altru Health System 7017803403	Lusignan, Sara Jane Chief Financial Officer Altru Health System 7017805203	8/13/2019 7:42 AM
Contacts	Authorizing Official	Update	Change Request	Berge, Scott Jerry Director of Finance Altru Health System 7017805542	Hamscher, Janice Chief Nursing Officer Altru Health System 7017803403	1/10/2019 4:10 PM
Details	State	Update		To Be Terminated	Terminated	1/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		9/30/2018 12:00:00 AM	10/12/2018 12:12 PM
Details	State	Update	Termination Request	Active	To Be Terminated	10/12/2018 12:12 PM
Terminations	Termination Date	Update	Termination Request		1/1/2019 12:00:00 AM	10/12/2018 12:12 PM
Terminations	Termination Effective Date	Update	Termination Request		10/1/2018 12:00:00 AM	10/12/2018 12:12 PM
Terminations	Termination Reason	Update	Termination Request		Other	10/12/2018 12:12 PM
Details	Last Recertification Date	Update	Recertification	11/15/2017 2:07:03 PM	8/27/2018 12:43:52 PM	8/27/2018 12:43 PM
Contacts	Authorizing Official	Update	Change Request	THOMPSON, DWIGHT William CFO Altru Health System 7017805211	Berge, Scott Jerry Director of Finance Altru Health System 7017805542	5/25/2018 12:44 PM
Details	Last Recertification Date	Update	Recertification	10/24/2017 12:17:12 PM	11/15/2017 2:07:03 PM	11/15/2017 2:07 PM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	10/24/2017 12:17:12 PM	10/24/2017 12:17 PM
Contacts	Authorizing Official	Update		THOMPSON, DWIGHT CFO 7017805211	THOMPSON, DWIGHT William CFO Altru Health System 7017805211	10/9/2017 4:44 PM
Contacts	Primary Contact	Update		Ellis, Cherri Supervisor, Budgeting & Cost Accounting 7017805724	Ellis, Cherri Supervisor, Budgeting & Cost Accounting Altru Health System 7017805724	10/9/2017 11:54 AM
Contacts	Authorizing Official	Insert			THOMPSON, DWIGHT CFO 7017805211	7/20/2017 3:14 PM
Contacts	Primary Contact	Insert			Ellis, Cherri Supervisor, Budgeting & Cost Accounting 7017805724	8/10/2016 9:25 AM
Addresses	Main Address	Insert			400 S.MINNESOTA STREET CROOKSTON, MN 56716	8/10/2016 9:20 AM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 9:20 AM
Details	Last Recertification Date	Update		8/15/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 4:07 PM
Details	Last Recertification Date	Update		8/28/2013 12:24:21 PM	8/15/2014 12:00:00 AM	8/15/2014 1:38 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/28/2013 12:24:21 PM	8/28/2013 12:24 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	4/23/2012 8:51 AM
Addresses	Billing Address	Insert			ALTRU HOSPITAL PO BOX 13780 GRAND FORKS, ND 58208-3780	8/5/2010 7:54 AM
Details	Last Recertification Date	Insert				8/5/2010 7:54 AM
Details	Grant Number	Insert				8/5/2010 7:54 AM
Details	340B ID	Insert			SCH350019-08	8/5/2010 7:54 AM
Details	Is Authorizing Official EHB Data	Insert				8/5/2010 7:54 AM
Dates	Last Date That 340B Drugs Purchased	Insert				8/5/2010 7:54 AM
Details	Medicare Provider Number	Insert			350019	8/5/2010 7:54 AM
Details	Entity Name	Insert			ALTRU HOSPITAL	8/5/2010 7:54 AM
Details	Program Code	Insert			SCH	8/5/2010 7:54 AM
Details	Entity Subname	Insert			ALTRU CLINIC - CROOKSTON	8/5/2010 7:54 AM
Dates	Participating Approval Date	Insert			8/4/2010 12:00:00 AM	8/5/2010 7:54 AM
Details	State	Insert			Active	8/5/2010 7:54 AM
Dates	Registration Date	Insert			8/4/2010 12:00:00 AM	8/5/2010 7:54 AM
Dates	Signed By Date	Insert			7/28/2010 12:00:00 AM	8/5/2010 7:54 AM
Dates	Start Date	Insert			8/5/2010 12:00:00 AM	8/5/2010 7:54 AM
Terminations	Termination Comments	Insert				8/5/2010 7:54 AM
Terminations	Termination Date	Insert				8/5/2010 7:54 AM
Terminations	Termination Effective Date	Insert				8/5/2010 7:54 AM
Terminations	Termination Reason	Insert				8/5/2010 7:54 AM