Covered Entity Details

CAH241325-00 CCM Health (Active) - information as of 5/15/2025 2:05:37 AM

Main Details

Name

CCM Health

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH241325-00

Medicare Provider Number

241325

Additional Details

Current Program Status

Active

Registration Date

11/28/2011

Participating Start Date

1/1/2012

Participating Approval Date

12/12/2011

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

CCM Health
Brian Lovdahl, CEO
(320) 321-8101

Primary Contact

CCM Health
Jamie L Malstrom, Director of Pharmacy
(320) 321-8175

Addresses

Street Address

824 N 11Th St
Montevideo, MN 56265

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		1720086028,1407636475

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	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	10/15/2021	01/01/2022	04/15/2022	05/10/2023
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/14/2022	04/15/2022		04/21/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/15/2021	01/01/2022		01/01/2022
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	10/15/2021	01/01/2022		01/01/2022
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	10/15/2021	01/01/2022		01/01/2022
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	10/15/2021	01/01/2022		01/01/2022
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	10/15/2021	01/01/2022		01/01/2022
Contract Detail	THRIFTY WHITE PHARMACY #770	724 E HIGHWAY 7		MONTEVIDEO	MN	56265-1638	01/07/2014	04/01/2014		04/25/2016
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/17/2014	10/01/2014		04/25/2016
Contract Detail	WAL-MART PHARMACY 10-1858	3001 EAST HWY 7, STE 100		MONTEVIDEO	MN	56265	01/07/2014	04/01/2014		04/25/2016
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/17/2014	10/01/2014		04/25/2016
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/04/2023	01/01/2024		01/01/2024
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/04/2023	01/01/2024		01/01/2024
Contract Detail	WHITE DRUG #52	706 38TH ST N STE B		FARGO	ND	58102-2953	01/13/2014	04/01/2014	07/14/2022	11/07/2023
Contract Detail	WHITE DRUG #61	706 38TH ST NW UNIT A		FARGO	ND	58102	01/13/2014	04/01/2014		04/25/2016

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH241325-01	Child	CAH	CCM Health	Montevideo Medical Clinic	824 North 11th Street	Montevideo	MN	Terminated
CAH241325-02	Child	CAH	CCM Health	Clara City Clinic	140 NW 1st Ave.	Clara City	MN	Terminated
CAH241325-03	Child	CAH	CCM Health	CLARKFIELD CLINIC - Clarkfield Clinic	812 10TH AVE	CLARKFIELD	MN	Terminated
CAH241325-04	Child	CAH	CCM Health	MILAN CLINIC - Milan Clinic	237 2ND ST	MILAN	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Change Request		1407636475	8/20/2024 2:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	8/20/2024 2:41 PM
Details	Last Recertification Date	Update	Recertification	8/16/2023 1:16:09 PM	8/13/2024 9:55:01 AM	8/13/2024 9:55 AM
Details	Last Recertification Date	Update	Recertification	8/26/2022 12:21:31 PM	8/16/2023 1:16:09 PM	8/16/2023 1:16 PM
Contacts	Authorizing Official	Update	Profile Change Request	Lovdahl, Brian CEO CCM Health 3203218200-3203218101	Lovdahl, Brian CEO CCM Health 3203218101	5/10/2023 9:50 AM
Details	Last Recertification Date	Update	Recertification	8/17/2021 9:32:57 AM	8/26/2022 12:21:31 PM	8/26/2022 12:21 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 1:00:20 PM	8/17/2021 9:32:57 AM	8/17/2021 9:32 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1720086028	6/10/2021 10:41 AM
Medicaid Billing	NPI: State	Insert	Change Request		MN	6/10/2021 10:41 AM
Contacts	Primary Contact	Update	Change Request	Padula, Samantha Director of Pharmacy CCM Health 3203218175	Malstrom, Jamie L Director of Pharmacy CCM Health 3203218175	11/16/2020 8:08 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 8:34:04 AM	9/8/2020 1:00:20 PM	9/8/2020 1:00 PM
Contacts	Primary Contact	Update	Profile Change Request	Padula, Samantha Director of Pharmacy CCM Health 3203218168-3203218175	Padula, Samantha Director of Pharmacy CCM Health 3203218175	8/27/2020 5:10 PM
Contacts	Authorizing Official	Update	Change Request	Lovdahl, Brian CEO CCM Health 3203218200	Lovdahl, Brian CEO CCM Health 3203218200-3203218101	4/8/2020 3:50 PM
Contacts	Primary Contact	Update	Change Request	Padula, Samantha Director of Pharmacy CCM Health 3203218168	Padula, Samantha Director of Pharmacy CCM Health 3203218168-3203218175	4/8/2020 3:09 PM
Details	Last Recertification Date	Update	Recertification	8/29/2018 4:14:56 PM	8/20/2019 8:34:04 AM	8/20/2019 8:34 AM
Contacts	Primary Contact	Update	Change Request	Padula, Samantha May Director of Pharmacy CCM Health 3203218168	Padula, Samantha Director of Pharmacy CCM Health 3203218168	8/12/2019 7:05 AM
Contacts	Authorizing Official	Update	Change Request	Lovdahl, Brian CEO CCM Health 3203218200	Lovdahl, Brian CEO CCM Health 3203218200	8/12/2019 7:05 AM
Details	Entity Name	Update	Change Request	Chippewa County Montevideo Hospital	CCM Health	8/12/2019 7:05 AM
Contacts	Authorizing Official	Update	Profile Change Request	Lovdahl, Brian CEO CCMH 3203218100	Lovdahl, Brian CEO CCM Health 3203218200	8/8/2019 2:41 PM
Contacts	Primary Contact	Update	Profile Change Request	Padula, Samantha May Director of Pharmacy Chippewa County Montevideo Hospital 3203218168	Padula, Samantha May Director of Pharmacy CCM Health 3203218168	8/7/2019 4:20 PM
Details	Last Recertification Date	Update	Recertification	11/7/2017 8:05:13 AM	8/29/2018 4:14:56 PM	8/29/2018 4:14 PM
Contacts	Authorizing Official	Update	Change Request	Lindgren, Jeremiah COO Chippewa County Montevideo Hospital 3203218274	Lovdahl, Brian CEO CCMH 3203218100	8/14/2018 7:37 AM
Contacts	Primary Contact	Update	Recertification	Paulson, Mark E. Administrator 3203218100	Padula, Samantha May Director of Pharmacy Chippewa County Montevideo Hospital 3203218168	11/7/2017 8:05 AM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	11/7/2017 8:05:13 AM	11/7/2017 8:05 AM
Contacts	Authorizing Official	Update	AO Change Request	Paulson, Mark E. Administrator 3203218100	Lindgren, Jeremiah COO Chippewa County Montevideo Hospital 3203218274	10/23/2017 2:25 PM
Addresses	Main Address	Insert			824 N 11Th St Montevideo, MN 56265	8/12/2016 12:10 PM
Contacts	Authorizing Official	Insert			Paulson, Mark E. Administrator 3203218100	8/12/2016 12:10 PM
Contacts	Primary Contact	Insert			Paulson, Mark E. Administrator 3203218100	8/12/2016 12:10 PM
Contacts	Signed By	Insert			Paulson, Mark E. Administrator 3203218100	8/12/2016 12:10 PM
Details	Last Recertification Date	Update		8/21/2015 12:00:00 AM	8/12/2016 12:00:00 AM	8/12/2016 12:10 PM
Details	Last Recertification Date	Update		8/6/2014 12:00:00 AM	8/21/2015 12:00:00 AM	8/21/2015 10:51 AM
Details	Last Recertification Date	Update		9/6/2013 12:00:00 AM	8/6/2014 12:00:00 AM	8/6/2014 9:57 AM
Details	Last Recertification Date	Update		9/6/2013 10:25:24 AM	9/6/2013 12:00:00 AM	4/11/2014 10:53 AM
Details	Last Recertification Date	Update			9/6/2013 10:25:24 AM	9/6/2013 10:25 AM
Dates	Participating Approval Date	Update			12/12/2011 12:00:00 AM	12/12/2011 9:58 AM
Details	State	Update		Pending	Active	12/12/2011 9:58 AM
Details	340B ID	Update		EMG112811	CAH241325-00	11/29/2011 12:20 PM
Dates	Start Date	Update			1/1/2012 12:00:00 AM	11/29/2011 12:20 PM
Details	340B ID	Update		ONLINE_REG	EMG112811	11/29/2011 9:39 AM
Details	Last Recertification Date	Insert				11/28/2011 5:35 PM
Details	Grant Number	Insert				11/28/2011 5:35 PM
Details	340B ID	Insert			ONLINE_REG	11/28/2011 5:35 PM
Details	Is Authorizing Official EHB Data	Insert				11/28/2011 5:35 PM
Dates	Last Date That 340B Drugs Purchased	Insert				11/28/2011 5:35 PM
Details	Medicare Provider Number	Insert			241325	11/28/2011 5:35 PM
Details	Entity Name	Insert			Chippewa County Montevideo Hospital	11/28/2011 5:35 PM
Details	Program Code	Insert			CAH	11/28/2011 5:35 PM
Details	Entity Subname	Insert				11/28/2011 5:35 PM
Dates	Participating Approval Date	Insert				11/28/2011 5:35 PM
Details	State	Insert			Pending	11/28/2011 5:35 PM
Dates	Registration Date	Insert			11/28/2011 12:00:00 AM	11/28/2011 5:35 PM
Dates	Signed By Date	Insert			11/28/2011 12:00:00 AM	11/28/2011 5:35 PM
Dates	Start Date	Insert				11/28/2011 5:35 PM
Terminations	Termination Comments	Insert				11/28/2011 5:35 PM
Terminations	Termination Date	Insert				11/28/2011 5:35 PM
Terminations	Termination Effective Date	Insert				11/28/2011 5:35 PM
Terminations	Termination Reason	Insert				11/28/2011 5:35 PM