Covered Entity Details

DSH240002 ST MARYS MEDICAL CENTER (Terminated) - information as of 5/19/2025 12:36:49 AM

Main Details

Name

ST MARYS MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH240002

Medicare Provider Number

240002

Additional Details

Current Program Status

Terminated

Registration Date

6/13/2011

Participating Start Date

7/1/2011

Participating Approval Date

6/14/2011

Last Recertification Date

8/30/2023

Termination Date
Termination Reason

10/1/2024
Change of covered entity type

Contacts

Authorizing Official

Essentia Health
Bradley Beard, Chief Operating Officer
(218) 786-2652

Primary Contact

Essentia Health
Nick Sharrow, Pharmacy Business Services Director
(218) 606-9246

Addresses

Street Address

402 E 2ND STREET
DULUTH, MN 55805

Billing Address
Same as Street Address

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		1457393035
MI		1457393035
ND		1457393035
WI		1457393035

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/05/2022	07/01/2022	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH BAXTER PHARMACY	13060 ISLE DR		BAXTER	MN	56425	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH BRAINERD PHARMACY	2024 S 6TH ST		BRAINERD	MN	56401-4529	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH DEERWOOD PHARMACY	24087 CUYUNA ST	STE 100	DEERWOOD	MN	56444	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH DETROIT LAKES PHARMACY	211 FRAZEE ST E		DETROIT LAKES	MN	56501-3503	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH DULUTH 1ST STREET PHARMA	420 E 1ST ST	SUITE A	DULUTH	MN	55805	10/01/2014	01/01/2015	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH DULUTH 2ND STREET PHARMA	402 E 2ND ST	SUITE 6320	DULUTH	MN	55805	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH DULUTH 3RD STREET PHARMA	400 E 3RD ST STE A		DULUTH	MN	55805-1951	10/01/2014	01/01/2015	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH ELY PHARMACY	1500 E SHERIDAN ST STE 100		ELY	MN	55731	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH GRAND RAPIDS PHARMACY	RETAIL PHARMACY - COLLECTOR	1542 GOLF COURSE RD STE 205	GRAND RAPIDS	MN	55744	04/13/2018	07/01/2018	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH HAYWARD PHARMACY	11134 N STATE ROAD 77 STE A		HAYWARD	WI	54843	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH HERMANTOWN PHARMACY	4855 W ARROWHEAD RD STE A		HERMANTOWN	MN	55811-3936	10/01/2014	01/01/2015	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH HIBBING PHARMACY	730 E 34TH ST STE A		HIBBING	MN	55746-2349	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH INTERNATIONAL FALLS PHAR	2501 KEENAN DRIVE	SUITE A	INTERNATIONAL FALLS	MN	56649	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH LAKESIDE PHARMACY	4621 E SUPERIOR ST STE A		DULUTH	MN	55804-2338	10/01/2014	01/01/2015	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH LAKEWALK PHARMACY	1502 LONDON RD STE 101		DULUTH	MN	55812-1787	10/01/2014	01/01/2015	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH MILLER HILL PHARMACY	1600 MILLER TRUNK HWY BLDG. D, STE 102		DULUTH	MN	55811	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH PINE RIVER PHARMACY	280 BARCLAY AVE STE 1100		PINE RIVER	MN	56474	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH PRESCRIPTION SERVICE CEN	204 BELKNAP ST STE 300		SUPERIOR	WI	54880-2905	10/14/2015	01/01/2016	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH SILVER BAY PHARMACY	99 EDISON BLVD STE L		SILVER BAY	MN	55614-1269	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH SPECIALTY PHARMACY	204 BELKNAP ST STE 200		SUPERIOR	WI	54880-2905	10/14/2015	01/01/2016	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH SUPERIOR BELKNAP PHARMAC	204 BELKNAP ST STE 100		SUPERIOR	WI	54880-2905	04/08/2021	07/01/2021	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH SUPERIOR EAST PHARMACY	2202 E 2ND ST STE 477		SUPERIOR	WI	54880-3779	10/01/2014	01/01/2015	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH SUPERIOR PHARMACY	3500 TOWER AVE STE A		SUPERIOR	WI	54880	10/01/2014	01/01/2015	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH TWO HARBORS PHARMACY	802 11TH ST STE C		TWO HARBORS	MN	55616-1670	10/01/2014	01/01/2015	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH VIRGINIA PHARMACY	1101 9TH ST N STE A		VIRGINIA	MN	55792-2329	04/15/2024	07/01/2024	10/01/2024	10/01/2024
Contract Detail	ESSENTIA HEALTH WEST DULUTH PHARMACY	4212 GRAND AVE	SUITE A	DULUTH	MN	55807-2737	10/01/2014	01/01/2015	10/01/2024	10/01/2024
Contract Detail	FAIRVIEW SPECIALTY SERVICES PHARMACY	711 KASOTA AVENUE SE, SUITE A		MINNEAPOLIS	MN	55414	04/13/2018	07/01/2018	01/15/2020	01/15/2020
Contract Detail	FAIRVIEW SPECIALTY SERVICES PHARMACY	711 KASOTA AVENUE SE, SUITE A		MINNEAPOLIS	MN	55414	01/17/2023	04/01/2023	10/01/2024	10/01/2024
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/05/2022	07/01/2022	05/13/2022	08/26/2022
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/17/2022	01/01/2023	10/01/2024	10/01/2024
Contract Detail	WAL-MART PHARMACY 10-1447	3705 TOWER AVENUE		SUPERIOR	WI	54880	10/17/2022	01/01/2023	10/01/2024	10/01/2024
Contract Detail	WAL-MART PHARMACY 10-1757	4740 WEST MALL DRIVE		HERMANTOWN	MN	55811	10/17/2022	01/01/2023	10/01/2024	10/01/2024
Contract Detail	WAL-MART PHARMACY 10-1929	1308 HWY 33 SOUTH		CLOQUET	MN	55720	10/17/2022	01/01/2023	10/01/2024	10/01/2024
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/17/2022	01/01/2023	10/01/2024	10/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 13877	1131 E. SUPERIOR STREET	DULUTH	MN	55802	01/19/2022	04/01/2022	10/01/2024	10/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10500	1201 MILLER TRUNK HWY	DULUTH	MN	55811-5633	01/19/2022	04/01/2022	10/01/2024	10/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07126	4501 GRAND AVENUE	DULUTH	MN	55807	01/19/2022	04/01/2022	10/01/2024	10/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03064	2015 TOWER AVENUE	SUPERIOR	WI	54880	01/19/2022	04/01/2022	10/01/2024	10/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15439	215 DODDRIDGE AVENUE	CLOQUET	MN	55720-2372	01/19/2022	04/01/2022	10/01/2024	10/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15149	1609 KENWOOD AVENUE	DULUTH	MN	55811	01/19/2022	04/01/2022	10/01/2024	10/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/19/2022	04/01/2022	10/01/2024	10/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/05/2022	07/01/2022	10/01/2024	10/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/05/2022	07/01/2022	10/01/2024	10/01/2024
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/04/2023	10/01/2023	10/01/2024	10/01/2024
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/17/2023	01/01/2024	10/01/2024	10/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH240002A	Child	DSH	ST MARYS MEDICAL CENTER	Essentia Health St. Marys Medical Center / Endoscopy	420 E 1ST ST	DULUTH	MN	Terminated
DSH240002B	Child	DSH	ST MARYS MEDICAL CENTER	Essentia Health St. Marys Medical Center / Anesthesia	420 E 1ST ST	DULUTH	MN	Terminated
DSH240002C	Child	DSH	ST MARYS MEDICAL CENTER	Essentia Health Duluth Clinic / - Pulmonary Function Lab	400 E 3RD STREET	DULUTH	MN	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		10/1/2024 12:00:00 AM	7/31/2024 12:36 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	7/31/2024 12:36 PM
Terminations	Termination Date	Update	Hospital Type Change Request		10/1/2024 12:00:00 AM	7/31/2024 12:36 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		10/1/2024 12:00:00 AM	7/31/2024 12:36 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	7/31/2024 12:36 PM
Contacts	Primary Contact	Update	Group Change Request	Brooks-Dockendorf, Rhonda 340B Program Coordinator Essentia Health 2187864423	Sharrow, Nick Pharmacy Business Services Director Essentia Health 2186069246	2/27/2024 1:02 PM
Contacts	Primary Contact	Update	Group Change Request	Sedlachek, Andrea 340B Senior Coordinator Essentia Health 2183936699	Brooks-Dockendorf, Rhonda 340B Program Coordinator Essentia Health 2187864423	11/7/2023 9:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457393035	10/31/2023 8:48 AM
Medicaid Billing	NPI: State	Insert	Change Request		WI	10/31/2023 8:48 AM
Details	Last Recertification Date	Update	Recertification	9/6/2022 6:52:07 AM	8/30/2023 6:33:40 AM	8/30/2023 6:33 AM
Addresses	Main Address	Update	Change Request	407 E 3RD ST DULUTH, MN 55805	402 E 2ND STREET DULUTH, MN 55805	8/2/2023 12:05 PM
Contacts	Primary Contact	Update	PC Change Request	Olivier, Ryan Pharmacy 340B Manager Essentia Health 2185760677	Sedlachek, Andrea 340B Senior Coordinator Essentia Health 2183936699	5/25/2023 9:31 AM
Details	Last Recertification Date	Update	Recertification	9/10/2021 9:10:49 AM	9/6/2022 6:52:07 AM	9/6/2022 6:52 AM
Contacts	Primary Contact	Update	Group Change Request	Kaufenberg, Anthony Vice President, Pharmacy Essentia Health 2188287693	Olivier, Ryan Pharmacy 340B Manager Essentia Health 2185760677	9/13/2021 7:43 AM
Details	Last Recertification Date	Update	Recertification	8/25/2020 6:44:48 PM	9/10/2021 9:10:49 AM	9/10/2021 9:10 AM
Contacts	Primary Contact	Update	Group Change Request	Heide, Dawn 340B Senior Program Coordinator Essentia Health 2188287143	Kaufenberg, Anthony Vice President, Pharmacy Essentia Health 2188287693	7/8/2021 4:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	95845 (AZ)		4/8/2021 4:31 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	178317 (OH)		4/8/2021 4:31 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100692660A (OK)		4/8/2021 4:31 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	251033281C (GA)		4/8/2021 4:31 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	90758800 (FL)		4/8/2021 4:31 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	251033281B (GA)		4/8/2021 4:31 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	410695604001 (KY)		4/8/2021 4:31 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100819005971 (OH)		4/8/2021 4:31 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	11003900 (WI)		4/8/2021 4:31 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457393035 (WI)		4/8/2021 4:31 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457393035 (SD)		4/8/2021 4:31 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457393035 (IA)		4/8/2021 4:31 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457393035 (IL)		4/8/2021 4:31 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457393035 (NY)		4/8/2021 4:31 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457393035 (CA)		4/8/2021 4:31 PM
Contacts	Primary Contact	Update	Change Request	Lundberg, Bryan 340b Program Manager Essentia Health 2188287143	Heide, Dawn 340B Senior Program Coordinator Essentia Health 2188287143	1/25/2021 10:40 AM
Contacts	Primary Contact	Update	Profile Change Request	Lundberg, Bryan 340b Program Manager Essentia Health 2185760745	Lundberg, Bryan 340b Program Manager Essentia Health 2188287143	10/9/2020 9:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	251033281B (GA)		8/25/2020 6:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457393035	8/25/2020 6:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/25/2020 6:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457393035	8/25/2020 6:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/25/2020 6:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457393035	8/25/2020 6:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		ND	8/25/2020 6:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457393035	8/25/2020 6:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		SD	8/25/2020 6:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457393035	8/25/2020 6:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/25/2020 6:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457393035	8/25/2020 6:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/25/2020 6:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457393035	8/25/2020 6:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/25/2020 6:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457393035	8/25/2020 6:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/25/2020 6:44 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	8/25/2020 6:44 PM
Details	Last Recertification Date	Update	Recertification	9/2/2019 3:36:38 PM	8/25/2020 6:44:48 PM	8/25/2020 6:44 PM
Contacts	Primary Contact	Update	Profile Change Request	Lundberg, Bryan 340b Program Manager Essentia 2185760745	Lundberg, Bryan 340b Program Manager Essentia Health 2185760745	4/1/2020 10:07 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		90758800	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		251033281B	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		410695604001	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100819005971	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11003900	1/15/2020 4:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	1/15/2020 4:17 PM
Addresses	Main Address	Update	Change Request	407 EAST THIRD STREET DULUTH, MN 55805	407 E 3RD ST DULUTH, MN 55805	10/9/2019 7:14 AM
Details	Entity Name	Update	Change Request	ST. MARY'S MEDICAL CENTER	ST MARYS MEDICAL CENTER	10/9/2019 7:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2019 3:36 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		251033281C	9/2/2019 3:36 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/2/2019 3:36 PM
Details	Last Recertification Date	Update	Recertification	9/7/2018 3:07:37 PM	9/2/2019 3:36:38 PM	9/2/2019 3:36 PM
Contacts	Authorizing Official	Update	Change Request	Garvey, James M. SVP Hospital Operations East Region Essentia Health 2187864878	Beard, Bradley Chief Operating Officer Essentia Health 2187862652	8/1/2019 12:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/10/2019 2:35 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		95845	6/10/2019 2:35 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	6/10/2019 2:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/10/2019 2:35 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		251033281B	6/10/2019 2:35 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	6/10/2019 2:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/10/2019 2:35 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		178317	6/10/2019 2:35 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	6/10/2019 2:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/10/2019 2:35 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100692660A	6/10/2019 2:35 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	6/10/2019 2:35 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 4:00:57 PM	9/7/2018 3:07:37 PM	9/7/2018 3:07 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/29/2017 4:00:57 PM	11/29/2017 4:00 PM
Contacts	Authorizing Official	Update		Garvey, James M. SVP Hospital Operations East Region 2187864878	Garvey, James M. SVP Hospital Operations East Region Essentia Health 2187864878	10/3/2017 10:42 AM
Contacts	Primary Contact	Update		Lundberg, Bryan 340b Program Manager 2185760745	Lundberg, Bryan 340b Program Manager Essentia 2185760745	9/20/2017 3:06 PM
Contacts	Primary Contact	Update		SPEHAR, RICHARD DIRECTOR OF PHARMACY 2187864509	Lundberg, Bryan 340b Program Manager 2185760745	8/14/2017 1:06 PM
Addresses	Main Address	Insert			407 EAST THIRD STREET DULUTH, MN 55805	8/11/2017 9:47 AM
Contacts	Authorizing Official	Update		McGinty, Daniel B. CEO 2187864878	Garvey, James M. SVP Hospital Operations East Region 2187864878	8/11/2017 9:47 AM
Details	Last Recertification Date	Update		9/3/2015 12:00:00 AM	8/30/2016 12:00:00 AM	8/30/2016 2:30 PM
Details	Last Recertification Date	Update		8/15/2014 12:00:00 AM	9/3/2015 12:00:00 AM	9/3/2015 9:45 AM
Medicaid Billing	NPI: Number	Insert			1457393035	10/30/2014 4:15 PM
Details	Last Recertification Date	Update		9/12/2013 12:00:00 AM	8/15/2014 12:00:00 AM	8/15/2014 7:45 AM
Contacts	Primary Contact	Insert			SPEHAR, RICHARD DIRECTOR OF PHARMACY 2187864509	7/30/2014 7:30 AM
Details	Last Recertification Date	Update			9/12/2013 12:00:00 AM	9/12/2013 8:38 PM
Contacts	Authorizing Official	Update		JOHNSON, BARBARA CFO 2187861421	McGinty, Daniel B. CEO 2187864878	6/4/2012 10:05 AM
Contacts	Authorizing Official	Insert			JOHNSON, BARBARA CFO 2187861421	6/14/2011 11:08 AM
Details	Last Recertification Date	Insert				6/14/2011 11:08 AM
Details	Grant Number	Insert				6/14/2011 11:08 AM
Details	340B ID	Insert			DSH240002	6/14/2011 11:08 AM
Details	Is Authorizing Official EHB Data	Insert				6/14/2011 11:08 AM
Dates	Last Date That 340B Drugs Purchased	Insert				6/14/2011 11:08 AM
Details	Medicare Provider Number	Insert			240002	6/14/2011 11:08 AM
Details	Entity Name	Insert			ST. MARY'S MEDICAL CENTER	6/14/2011 11:08 AM
Details	Program Code	Insert			DSH	6/14/2011 11:08 AM
Details	Entity Subname	Insert				6/14/2011 11:08 AM
Dates	Participating Approval Date	Insert			6/14/2011 12:00:00 AM	6/14/2011 11:08 AM
Details	State	Insert			Active	6/14/2011 11:08 AM
Dates	Registration Date	Insert			6/13/2011 12:00:00 AM	6/14/2011 11:08 AM
Dates	Signed By Date	Insert			1/31/2011 12:00:00 AM	6/14/2011 11:08 AM
Dates	Start Date	Insert			7/1/2011 12:00:00 AM	6/14/2011 11:08 AM
Terminations	Termination Comments	Insert				6/14/2011 11:08 AM
Terminations	Termination Date	Insert				6/14/2011 11:08 AM
Terminations	Termination Effective Date	Insert				6/14/2011 11:08 AM
Terminations	Termination Reason	Insert				6/14/2011 11:08 AM