Covered Entity Details

DSH240080K UNIVERSITY OF MINNESOTA MEDICAL CENTER (Active) - information as of 4/29/2025 2:52:25 AM

Main Details

Name

UNIVERSITY OF MINNESOTA MEDICAL CENTER

Subdivision Name

UMMC Lakes Cancer Clinic and Infusion

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240080K

Medicare Provider Number

240080

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

5/31/2012

Participating Start Date

7/1/2012

Participating Approval Date

6/25/2012

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

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

Primary Contact

Fairview Health Services
Bryan John Lundberg, VP 340B Program
(218) 340-4695

Addresses

Street Address

5200 Fairview Blvd
Suite 1300
Wyoming, MN 55092

Billing Address

Fairview Health Services
PO Box 59318
Minneapolis, MN 55459

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	616845100	1013994359,1942345210,1659632743,1649531732,1093919482,1427193937,1104956929,1003289257

Shipping Addresses

Shipping Address 1

Fairview Lakes Health Services Pharmacy
5200 Fairview Blvd
Wyoming, MN 55092

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
Contract Detail	FAIRVIEW EDINA PHARMACY	6363 FRANCE AVENUE SOUTH		EDINA	MN	55435	12/09/2016	01/01/2017	10/01/2016	01/15/2020	01/15/2020
Contract Detail	FAIRVIEW EDINA PHARMACY	6401 FRANCE AVE S # SL-1		EDINA	MN	55435-2104	10/17/2019	10/17/2019	10/17/2019		10/31/2019
Contract Detail	FAIRVIEW LAKES PHARMACY WYOMING	5200 FAIRVIEW BOULEVARD		WYOMING	MN	55092	12/09/2016	01/01/2017	10/01/2016		08/30/2019
Contract Detail	FAIRVIEW PHARMACY BURNSVILLE SCC	14101 FAIRVIEW DRIVE	SUITE 100	BURNSVILLE	MN	55337	12/09/2016	01/01/2017	10/01/2016		08/30/2019
Contract Detail	FAIRVIEW RIVERSIDE PHARMACY	606 24TH AVENUE SOUTH		MINNEAPOLIS	MN	55454	12/09/2016	01/01/2017	10/01/2016		08/30/2019
Contract Detail	FAIRVIEW SPECIALTY SERVICES PHARMACY	711 KASOTA AVENUE SE, SUITE A		MINNEAPOLIS	MN	55414	12/09/2016	01/01/2017	10/01/2016		08/30/2019
Contract Detail	FAIRVIEW UNIVERSITY CLINIC PHARMACY	909 FULTON STREET SE, 1ST FLOOR	MAIL CODE 2121AA	MINNEAPOLIS	MN	55455	12/09/2016	01/01/2017	10/01/2016		08/30/2019
Contract Detail	FAIRVIEW UNIVERSITY DISCHARGE PHARMACY	500 HARVARD ST SE ROOM 3-017		MINNEAPOLIS	MN	55455	12/09/2016	01/01/2017	10/01/2016	01/15/2020	01/15/2020
Contract Detail	FAIRVIEW UNIVERSITY DISCHARGE PHARMACY	500 HARVARD ST SE # 2-130K	MMC 812	MINNEAPOLIS	MN	55455-0363	10/17/2019	10/17/2019	10/17/2019		10/31/2019

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH240080AA	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Physical Med and Rehab Clinics	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AB	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Gynecologic Cancer Clinic	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AC	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Diagnostic Imaging Center	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AD	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Surgery Clinics	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AE	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Outpatient Interventional & Diagnostic Centers	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AF	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Solid Organ Transplant	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080AG	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Primary Care Center	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AH	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Dermatology Surgery and Laser Clinic	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AJ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Cardiology Clinics	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080AK	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Derm Rheumatology Clinic	909 Fulton Street SE	Minneapolis	MN	Terminated
DSH240080AL	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Blood and Marrow Transplant Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080AM	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Medicine Specialty Clinics	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AN	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Bleeding and Clotting Disorders	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080AP	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Infectious Disease Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080AQ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Ear, Nose, and Throat Clinics	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AR	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Eye Clinics	516 Delaware St. SE	Minneapolis	MN	Active
DSH240080AS	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric ENT Clinics	701 25th Ave S	Minneapolis	MN	Active
DSH240080AT	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	University Specialists in Women's Health	606 24th Ave S	Minneapolis	MN	Active
DSH240080AU	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Eye Clinics	701 25th Ave S	Minneapolis	MN	Active
DSH240080AV	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Palliative Care Clinic	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AW	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Lakes Cancer Infusion Center	5200 Fairview Blvd	Wyoming	MN	Terminated
DSH240080AX	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Southdale Cancer Clinic and Infusion	6363 France Ave So	Edina	MN	Active
DSH240080AY	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Autism Clinic	2512 S 7th St	Minneapolis	MN	Terminated
DSH240080AZ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Aphaeresis Blood Donation	2450 Riverside Ave	Minneapolis	MN	Terminated
DSH240080BA	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Emergency Room	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080BB	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Emergency Room	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080BC	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Electroconvulsive Therapy	525 23rd Ave. South	Minneapolis	MN	Active
DSH240080BD	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Psychiatric Emergency Room	2312 S. 6th Street	Minneapolis	MN	Terminated
DSH240080BE	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Ridges Cancer Clinic and Infusion	14101 Fairview Drive Suite 200	Burnsville	MN	Active
DSH240080BF	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Advanced Treatment Center - Apheresis	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BG	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Center for Lung Science	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BH	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Hepatology Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BJ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Nephrology Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BK	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Rheumatology Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BL	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Multiple Sclerosis & Neuro Specialty Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BM	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Riverside Operating Suites - Same Day Surgery	2450 Riverside Ave.	Minneapolis	MN	Active
DSH240080BN	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Sedation - Pediatrics	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080BP	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Riverside CT Scan - Imaging Services	2450 Riverside Avenue	Minneapolis	MN	Active
DSH240080BQ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Sleep Center - Sleep Medicine	606 24th Avenue South	Minneapolis	MN	Terminated
DSH240080BR	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Breast Center - Oncology	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BS	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Interventional Radiology - Interventional Imaging	2450 Riverside Avenue	Minneapolis	MN	Active
DSH240080BT	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Voyager Pediatric Specialty Clinic - Pediatric	2512 South 7th Street	Minneapolis	MN	Active
DSH240080BU	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Rheumatology - Rheumatology	606 24th Avenue South	Minneapolis	MN	Active
DSH240080BV	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMCH Heart Catheterization - Pediatric Cardiac Cath Lab	2450 RIVERSIDE AVE	Minneapolis	MN	Active
DSH240080BW	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Medication Management Clinic - Medication Therapy Management	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BX	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Maple Grove Cancer Infusion - Infusion Therapy	14500 99th Avenue North	Maple Grove	MN	Active
DSH240080BY	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	M Health Fairview UMMC Pre Anesthesia Clinic - Surgery	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080BZ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	MHealth Fairview Mental Health and Addiction Clinic - CD Adult Eval - Behavioral Health	2312 SOUTH 6TH STREET	Minneapolis	MN	Active
DSH240080CA	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	MHealth Fairview Mental Health and Addiction Clinic - MH Senior Intensive Outpatient - Behavioral Health	525 23rd Ave S	Minneapolis	MN	Active
DSH240080CB	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Maternal Fetal Med Clinic - Maternal Fetal Medicine	606 24TH AVE S	Minneapolis	MN	Active
DSH240080CC	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Maple Grove Cancer Clinic - Oncology	14500 99th Avenue North	Maple Grove	MN	Active
DSH240080CD	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Medication Management Clinic Riverside - Medication Therapy Management	2450 Riverside Avenue	Minneapolis	MN	Active
DSH240080J	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	ADVANCED TREATMENT CENTER	909 FULTON ST. SE	MINNEAPOLIS	MN	Active
DSH240080K	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Lakes Cancer Clinic and Infusion	5200 Fairview Blvd	Wyoming	MN	Active
DSH240080L	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Psychiatry Clinics	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080M	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Explorer Clinic	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080N	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Dialysis Clinic	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080P	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Journey Clinic and Infusion	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080Q	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Behavioral Health Services	2312 S. 6th Street	Minneapolis	MN	Active
DSH240080R	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Discovery Clinic	2512 S 7th St	Minneapolis	MN	Active
DSH240080S	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Orthopaedic Clinic	2512 S 7th St	Minneapolis	MN	Terminated
DSH240080T	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC-Fairview Rehabilitation Services	2512 S 7th St	Minneapolis	MN	Terminated
DSH240080U	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Fairview Adult Infusion Clinic	606 24th Ave So	Minneapolis	MN	Active
DSH240080V	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Prostate, Urologic & Dialysis	420 Delaware St SE	Minneapolis	MN	Terminated
DSH240080W	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Cancer Clinics	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080X	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Masonic Infusion Center	424 Harvard St. SE	Minneapolis	MN	Terminated
DSH240080Y	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Neurology Clinics	516 Delaware St SE	Minneapolis	MN	Terminated
DSH240080Z	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pain Management Clinics	516 Delaware St. SE	Minneapolis	MN	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Lundberg, Bryan John 340B Program Director Fairview Health Services 2183404695	Lundberg, Bryan John VP 340B Program Fairview Health Services 2183404695	3/24/2025 12:48 PM
Details	Last Recertification Date	Update	Recertification	9/7/2023 11:11:40 AM	8/26/2024 11:22:19 AM	8/26/2024 11:22 AM
Details	Last Recertification Date	Update	Recertification	12/12/2022 4:34:38 PM	9/7/2023 11:11:40 AM	9/7/2023 11:11 AM
Details	Last Recertification Date	Update	Recertification	8/26/2021 1:09:53 PM	12/12/2022 4:34:38 PM	12/12/2022 4:34 PM
Details	Last Recertification Date	Update	Recertification	9/3/2020 2:48:29 PM	8/26/2021 1:09:53 PM	8/26/2021 1:09 PM
Contacts	Primary Contact	Update	Change Request	Teich, Daniel VP, Pharmacy Purchasing and Contracting Fairview Health Services 6513878904	Lundberg, Bryan John 340B Program Director Fairview Health Services 2183404695	11/6/2020 7:55 AM
Medicaid Billing	NPI: State	Update	Recertification		MN	9/3/2020 2:48 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	9/3/2020 2:48 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	9/3/2020 2:48 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	9/3/2020 2:48 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	9/3/2020 2:48 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	9/3/2020 2:48 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	9/3/2020 2:48 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	9/3/2020 2:48 PM
Details	Last Recertification Date	Update	Recertification	8/30/2019 4:12:27 PM	9/3/2020 2:48:29 PM	9/3/2020 2:48 PM
Contacts	Primary Contact	Update	Change Request	Peterson, Jesse 340B Program Director University of Minnesota Medical Center 6126725179	Teich, Daniel VP, Pharmacy Purchasing and Contracting Fairview Health Services 6513878904	8/24/2020 10:22 AM
Details	Last Recertification Date	Update	Recertification	8/29/2018 10:10:17 AM	8/30/2019 4:12:27 PM	8/30/2019 4:12 PM
Contacts	Primary Contact	Update	Change Request	Cooper, Charles 340B Program Manager University of Minnesota Medical Center 6126725179	Peterson, Jesse 340B Program Director University of Minnesota Medical Center 6126725179	4/15/2019 10:12 AM
Contacts	Authorizing Official	Update	Change Request	Fromm, Daniel M. Sr. VP and CFO, Fairview Health Services Fairview Health Services 6126724976	Trysla, Trudi Noel Chief Legal Officer Fairview Health Services 6126726382	4/11/2019 2:24 PM
Details	Last Recertification Date	Update	Recertification	11/21/2017 3:11:25 PM	8/29/2018 10:10:17 AM	8/29/2018 10:10 AM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/21/2017 3:11:25 PM	11/21/2017 3:11 PM
Contacts	Authorizing Official	Update		Fromm, Daniel M. Sr. VP and CFO, Fairview Health Services 6126724976	Fromm, Daniel M. Sr. VP and CFO, Fairview Health Services Fairview Health Services 6126724976	10/24/2017 1:37 PM
Contacts	Signed By	Update		Fromm, Daniel M. Sr. VP and CFO, Fairview Health Services 6126724976	Fromm, Daniel M. Sr. VP and CFO, Fairview Health Services Fairview Health Services 6126724976	10/24/2017 1:37 PM
Contacts	Primary Contact	Update		Cooper, Charles 340B Program Manager 6126725179	Cooper, Charles 340B Program Manager University of Minnesota Medical Center 6126725179	10/10/2017 1:42 PM
Contacts	Primary Contact	Insert			Cooper, Charles 340B Program Manager 6126725179	6/1/2017 11:59 AM
Contacts	Authorizing Official	Insert			Fromm, Daniel M. Sr. VP and CFO, Fairview Health Services 6126724976	3/27/2017 9:29 AM
Contacts	Signed By	Insert			Fromm, Daniel M. Sr. VP and CFO, Fairview Health Services 6126724976	3/27/2017 9:29 AM
Addresses	Main Address	Insert			5200 Fairview Blvd Suite 1300 Wyoming, MN 55092	12/9/2016 11:27 AM
Addresses	Billing Address	Insert			Fairview Health Services PO Box 59318 Minneapolis, MN 55459	12/9/2016 11:27 AM
Addresses	Shipping Address	Insert			Fairview Lakes Health Services Pharmacy 5200 Fairview Blvd Wyoming, MN 55092	12/9/2016 11:27 AM
Medicaid Billing	NPI: Number	Insert			1942345210	12/9/2016 11:27 AM
Medicaid Billing	NPI: Number	Insert			1659632743	12/9/2016 11:27 AM
Medicaid Billing	NPI: Number	Insert			1649531732	12/9/2016 11:27 AM
Medicaid Billing	NPI: Number	Insert			1093919482	12/9/2016 11:27 AM
Medicaid Billing	NPI: Number	Insert			1427193937	12/9/2016 11:27 AM
Medicaid Billing	NPI: Number	Insert			1104956929	12/9/2016 11:27 AM
Medicaid Billing	NPI: Number	Insert			1003289257	12/9/2016 11:27 AM
Details	Last Recertification Date	Update		8/24/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 9:27 AM
Details	Entity Subname	Update		UMMC Lakes Cancer Infusion	UMMC Lakes Cancer Clinic and Infusion	3/15/2016 11:11 AM
Medicaid Billing	Medicaid: Number	Update		240080	616845100	3/2/2016 9:41 AM
Details	Last Recertification Date	Update		8/19/2014 12:00:00 AM	8/24/2015 12:00:00 AM	8/24/2015 12:15 PM
Details	Last Recertification Date	Update		8/30/2013 12:00:00 AM	8/19/2014 12:00:00 AM	8/19/2014 11:34 AM
Details	Last Recertification Date	Update			8/30/2013 12:00:00 AM	8/30/2013 7:54 PM
Details	340B ID	Update		IS-DSH240080K	DSH240080K	6/25/2012 3:42 PM
Dates	Participating Approval Date	Update			6/25/2012 12:00:00 AM	6/25/2012 3:42 PM
Details	State	Update		Pending	Active	6/25/2012 3:42 PM
Dates	Start Date	Update			7/1/2012 12:00:00 AM	6/25/2012 3:42 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-DSH240080K	6/7/2012 9:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	5/31/2012 10:39 AM
Medicaid Billing	Medicaid: Number	Insert			240080	5/31/2012 10:39 AM
Medicaid Billing	Medicaid: State	Insert			MN	5/31/2012 10:39 AM
Medicaid Billing	NPI: Number	Insert			1013994359	5/31/2012 10:39 AM
Details	Last Recertification Date	Insert				5/31/2012 10:39 AM
Details	Grant Number	Insert				5/31/2012 10:39 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	5/31/2012 10:39 AM
Details	Is Authorizing Official EHB Data	Insert				5/31/2012 10:39 AM
Dates	Last Date That 340B Drugs Purchased	Insert				5/31/2012 10:39 AM
Details	Medicare Provider Number	Insert			240080	5/31/2012 10:39 AM
Details	Entity Name	Insert			UNIVERSITY OF MINNESOTA MEDICAL CENTER	5/31/2012 10:39 AM
Details	Program Code	Insert			DSH	5/31/2012 10:39 AM
Details	Entity Subname	Insert			UMMC Lakes Cancer Infusion	5/31/2012 10:39 AM
Dates	Participating Approval Date	Insert				5/31/2012 10:39 AM
Details	State	Insert			Pending	5/31/2012 10:39 AM
Dates	Registration Date	Insert			5/31/2012 12:00:00 AM	5/31/2012 10:39 AM
Dates	Signed By Date	Insert			5/31/2012 12:00:00 AM	5/31/2012 10:39 AM
Dates	Start Date	Insert				5/31/2012 10:39 AM
Terminations	Termination Comments	Insert				5/31/2012 10:39 AM
Terminations	Termination Date	Insert				5/31/2012 10:39 AM
Terminations	Termination Effective Date	Insert				5/31/2012 10:39 AM
Terminations	Termination Reason	Insert				5/31/2012 10:39 AM