Covered Entity Details

CAH241370-03 ST. GABRIEL'S HOSPITAL (Active) - information as of 5/8/2025 10:18:49 PM

Main Details

Name

ST. GABRIEL'S HOSPITAL

Subdivision Name

RANDALL LAKES AREA CLINIC

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH241370-03

Medicare Provider Number

241370

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

8/15/2012

Participating Start Date

10/1/2012

Participating Approval Date

8/29/2012

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

St Gabriel's Hospital
STEVEN SMITH, President
(320) 631-5600

Primary Contact

CommonSpirit Health - Central Region
Mitchell Schultz, RPh, 340b Regional Manager
(701) 928-0620

Addresses

Street Address

250 WHITE OAK DRIVE
RANDALL, MN 56475

Billing Address

St. Gabriel's Hospital
815 2nd St.S. E.
Little Falls, MN 56345

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	380347300	1336359009

Shipping Addresses

Shipping Address 1

Unity Family Healthcare Pharmacy
Suite 4410
815 2nd St. S.E.
Little Falls, MN 56345

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	THRIFTY WHITE PHARMACY #779	112A MAIN ST S	PO BOX 279	PIERZ	MN	56364-4400	07/18/2018	10/01/2018	10/01/2018
Contract Detail	WHITE DRUG #52	706 38TH ST N STE B		FARGO	ND	58102-2953	07/18/2018	10/01/2018	10/01/2018
Contract Detail	WHITE DRUG #61	706 38TH ST NW UNIT A		FARGO	ND	58102	07/18/2018	10/01/2018	10/01/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH241370-01	Child	CAH	ST. GABRIEL'S HOSPITAL	COMMUNITY MEDICAL CENTER/ FAMILY MEDICAL CENTER	200 1ST AVE. S.E.	PIERZ	MN	Active
CAH241370-02	Child	CAH	ST. GABRIEL'S HOSPITAL	FAMILY MEDICAL CENTER	811 2ND ST. S.E.	LITTLE FALLS	MN	Active
CAH241370-03	Child	CAH	ST. GABRIEL'S HOSPITAL	RANDALL LAKES AREA CLINIC	250 WHITE OAK DRIVE	RANDALL	MN	Active
CAH241370-04	Child	CAH	ST. GABRIEL'S HOSPITAL	Little Falls Orthopedics	1108 1ST ST. S.E.	LITTLE FALLS	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 11:01:10 AM	8/19/2024 10:24:04 AM	8/19/2024 10:24 AM
Contacts	Primary Contact	Update	Profile Change Request	Schultz, Mitchell RPh, 340b Division Manager CommonSpirit Health - Midwest Division 7019280620	Schultz, Mitchell RPh, 340b Regional Manager CommonSpirit Health - Central Region 7019280620	8/6/2024 1:57 PM
Contacts	Primary Contact	Update	Profile Change Request	Schultz, Mitchell RPh CommonSpirit Health - Midwest Division 7019280620	Schultz, Mitchell RPh, 340b Division Manager CommonSpirit Health - Midwest Division 7019280620	9/27/2023 5:22 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 10:03:59 AM	8/23/2023 11:01:10 AM	8/23/2023 11:01 AM
Details	Last Recertification Date	Update	Recertification	9/6/2021 9:20:05 AM	8/31/2022 10:03:59 AM	8/31/2022 10:03 AM
Contacts	Primary Contact	Update	Profile Change Request	Schultz, Mitchell RPh CHI St. Alexius Health Carrington 7019280620	Schultz, Mitchell RPh CommonSpirit Health - Midwest Division 7019280620	3/10/2022 3:00 PM
Contacts	Primary Contact	Update	Group Change Request	KENNA, HOWARD PHARMACY DIRECTOR St. Gabriel's Hospital 3206315701	Schultz, Mitchell RPh CHI St. Alexius Health Carrington 7019280620	2/22/2022 7:14 AM
Details	Last Recertification Date	Update	Recertification	8/26/2020 11:06:26 AM	9/6/2021 9:20:05 AM	9/6/2021 9:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1336359009	8/26/2020 11:06 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	8/26/2020 11:06 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1336359009 ( )		8/26/2020 11:06 AM
Details	Last Recertification Date	Update	Recertification	9/3/2019 4:11:43 PM	8/26/2020 11:06:26 AM	8/26/2020 11:06 AM
Contacts	Authorizing Official	Update	Profile Change Request	SMITH, STEVEN CFO St Gabriel's Hospital 3206315670	SMITH, STEVEN President St Gabriel's Hospital 3206315600	9/5/2019 1:07 PM
Details	Last Recertification Date	Update	Recertification	8/27/2018 10:23:04 AM	9/3/2019 4:11:43 PM	9/3/2019 4:11 PM
Details	Last Recertification Date	Update	Recertification	11/10/2017 3:30:59 PM	8/27/2018 10:23:04 AM	8/27/2018 10:23 AM
Addresses	Shipping Address	Insert	Change Request		Unity Family Healthcare Pharmacy Suite 4410 815 2nd St. S.E. Little Falls, MN 56345	3/8/2018 12:50 PM
Addresses	Shipping Address	Delete	Change Request	St. Gabriel's Hospital 815 2nd St. S.E. Little Falls, MN 56345		3/8/2018 12:50 PM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	11/10/2017 3:30:59 PM	11/10/2017 3:30 PM
Contacts	Authorizing Official	Update		SMITH, STEVEN CFO 3206315670	SMITH, STEVEN CFO St Gabriel's Hospital 3206315670	10/23/2017 3:22 PM
Contacts	Primary Contact	Update		KENNA, HOWARD PHARMACY DIRECTOR 3206315701	KENNA, HOWARD PHARMACY DIRECTOR St. Gabriel's Hospital 3206315701	9/18/2017 4:20 PM
Contacts	Authorizing Official	Update		SMITH, STEVEN CFO 3206315670	SMITH, STEVEN CFO 3206315670	9/11/2017 3:29 PM
Contacts	Primary Contact	Insert			KENNA, HOWARD PHARMACY DIRECTOR 3206315701	5/4/2017 8:06 AM
Contacts	Signed By	Insert			SMITH, STEVEN CFO 3206315670	11/16/2016 8:54 AM
Contacts	Authorizing Official	Insert			SMITH, STEVEN CFO 3206315670	11/16/2016 8:54 AM
Addresses	Main Address	Insert			250 WHITE OAK DRIVE RANDALL, MN 56475	11/16/2016 8:54 AM
Addresses	Billing Address	Insert			St. Gabriel's Hospital 815 2nd St.S. E. Little Falls, MN 56345	11/16/2016 8:54 AM
Addresses	Shipping Address	Insert			St. Gabriel's Hospital 815 2nd St. S.E. Little Falls, MN 56345	11/16/2016 8:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	11/16/2016 8:54 AM
Medicaid Billing	Medicaid: Number	Insert			380347300	11/16/2016 8:54 AM
Medicaid Billing	Medicaid: State	Insert			MN	11/16/2016 8:54 AM
Medicaid Billing	NPI: Number	Insert			1336359009	11/16/2016 8:54 AM
Details	Last Recertification Date	Update		8/13/2015 12:00:00 AM	8/12/2016 12:00:00 AM	8/12/2016 10:00 AM
Details	Last Recertification Date	Update		9/4/2014 12:00:00 AM	8/13/2015 12:00:00 AM	8/13/2015 4:12 PM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	9/4/2014 12:00:00 AM	9/4/2014 3:21 PM
Details	Last Recertification Date	Update		9/9/2013 3:53:23 PM	9/9/2013 12:00:00 AM	9/12/2013 9:20 PM
Details	Last Recertification Date	Update			9/9/2013 3:53:23 PM	9/9/2013 3:53 PM
Details	340B ID	Update		ISDMCAH241370-03	CAH241370-03	8/29/2012 11:28 AM
Dates	Participating Approval Date	Update			8/29/2012 12:00:00 AM	8/29/2012 11:28 AM
Details	State	Update		Pending	Active	8/29/2012 11:28 AM
Dates	Start Date	Update			10/1/2012 12:00:00 AM	8/29/2012 11:28 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISDMCAH241370-03	8/23/2012 6:08 PM
Details	Last Recertification Date	Insert				8/15/2012 12:59 PM
Details	Grant Number	Insert				8/15/2012 12:59 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	8/15/2012 12:59 PM
Details	Is Authorizing Official EHB Data	Insert				8/15/2012 12:59 PM
Dates	Last Date That 340B Drugs Purchased	Insert				8/15/2012 12:59 PM
Details	Medicare Provider Number	Insert			241370	8/15/2012 12:59 PM
Details	Entity Name	Insert			ST. GABRIEL'S HOSPITAL	8/15/2012 12:59 PM
Details	Program Code	Insert			CAH	8/15/2012 12:59 PM
Details	Entity Subname	Insert			RANDALL LAKES AREA CLINIC	8/15/2012 12:59 PM
Dates	Participating Approval Date	Insert				8/15/2012 12:59 PM
Details	State	Insert			Pending	8/15/2012 12:59 PM
Dates	Registration Date	Insert			8/15/2012 12:00:00 AM	8/15/2012 12:59 PM
Dates	Signed By Date	Insert			8/15/2012 12:00:00 AM	8/15/2012 12:59 PM
Dates	Start Date	Insert				8/15/2012 12:59 PM
Terminations	Termination Comments	Insert				8/15/2012 12:59 PM
Terminations	Termination Date	Insert				8/15/2012 12:59 PM
Terminations	Termination Effective Date	Insert				8/15/2012 12:59 PM
Terminations	Termination Reason	Insert				8/15/2012 12:59 PM