Covered Entity Details

DSH240038 United Hospital (Active) - information as of 4/30/2025 12:01:02 AM

Main Details

Name

United Hospital

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240038

Medicare Provider Number

240038

Additional Details

Current Program Status

Active

Registration Date

8/30/2012

Participating Start Date

10/1/2013

Participating Approval Date

9/15/2013

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Allina Health
Tony M Collins-Kwong, Director, Strategic Sourcing and Services, Pharmacy Services
(612) 262-4785

Primary Contact

Allina Health
Jeremy Enger, 340B Program Manager
(612) 760-7836

Addresses

Street Address

333 North Smith Ave
St Paul, MN 55102

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
9/15/13 Enrolled 10/1/2012 and terminated 7/1/2013 due to a reported DSH percentage below the statutory minimum. Ineligible from 7/1/2013 through 9/30/2013; reinstated effective 10/1/2013.	09/15/2013

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	281747100,281747101,281747102,061214600,140198000,197132000,314322800,403485000,844998000,952657900	1457319485,1760440713,1174581151,1316901333,1700840097,1295799518,1780648964,1598822686,1760446124,1942264270,1780094698,1063449213,1699739045,1851355135,1104880384,1982641346
WI	281747100,844998000,952657900,403485000,061214600,314322800,197132000,140198000,281747101,281747102	1457319485,1760440713,1174581151

Shipping Addresses

Shipping Address 1

United Hospital Pharmacy
333 North Smith Ave
St. Paul, MN 55102

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	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	10/13/2023	01/01/2024			01/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/13/2023	01/01/2024			01/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/13/2023	01/01/2024			01/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	2915 WATERS RD STE 109		EAGAN	MN	55121-1562	04/04/2025	07/01/2025			04/04/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/13/2023	01/01/2024			01/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/13/2023	01/01/2024			01/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	10/13/2023	01/01/2024			01/01/2024
Contract Detail	ALLINA HEALTH APPLE VALLEY PHARMACY	14655 GALAXIE AVE		APPLE VALLEY	MN	55124-8602	04/14/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH CAMBRIDGE PHARMACY	701 DELLWOOD ST S		CAMBRIDGE	MN	55008-1920	04/14/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH COTTAGE GROVE PHARMACY	8611 W POINT DOUGLAS RD S		COTTAGE GROVE	MN	55016-4005	04/14/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH FARIBAULT PHARMACY	200 STATE AVE		FARIBAULT	MN	55021	10/04/2023	01/01/2024	04/01/2024		03/28/2024
Contract Detail	ALLINA HEALTH HEART HOSPITAL PHARMACY	920 E 28TH ST STE H1254		MINNEAPOLIS	MN	55407	10/14/2019	01/01/2020	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH MERCY PHARMACY	11850 BLACKFOOT ST. NW	STE 190	COON RAPIDS	MN	55433	10/04/2023	01/01/2024	04/01/2024		03/28/2024
Contract Detail	ALLINA HEALTH NEW ULM PHARMACY	1217 8TH ST N STE 1010		NEW ULM	MN	56073-1552	10/04/2023	01/01/2024	04/01/2024		03/28/2024
Contract Detail	ALLINA HEALTH PIPER BUILDING PHARMACY	913 E 26TH ST	1ST FLOOR PIPER BUILDING	MINNEAPOLIS	MN	55404	04/14/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH REGINA HOSPITAL	1175 NININGER RD		HASTINGS	MN	55033-1056	07/13/2022	10/01/2022			10/01/2022
Contract Detail	ALLINA HEALTH RITCHIE PHARMACY		280 NORTH SMITH AVE SUITE 120	ST PAUL	MN	55102	10/14/2013	01/01/2014		05/02/2016	05/13/2016
Contract Detail	ALLINA HEALTH ST. FRANCIS PHARMACY	1455 SAINT FRANCIS AVE STE 100		SHAKOPEE	MN	55379-3374	10/04/2023	01/01/2024	04/01/2024		03/28/2024
Contract Detail	ALLINA HEALTH UNITED PHARMACY	333 SMITH AVE N		SAINT PAUL	MN	55102-2344	10/14/2013	01/01/2014	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH UNITY PHARMACY	550 OSBORNE RD NE		FRIDLEY	MN	55432-2718	04/14/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH WESTHEALTH PHARMACY	2855 CAMPUS DR		PLYMOUTH	MN	55441	04/10/2023	07/01/2023			07/01/2023
Contract Detail	ALLINA HEALTH WOODBURY PHARMACY	8675 VALLEY CREEK RD		WOODBURY	MN	55125-2337	04/14/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	10/07/2022	01/01/2023			01/01/2023
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	10/07/2022	01/01/2023			01/01/2023
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	07/10/2024	10/01/2024			10/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	07/10/2024	10/01/2024			10/01/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/11/2023	01/01/2024			01/01/2024
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	10/06/2023	01/01/2024			01/01/2024
Contract Detail	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	10/07/2022	01/01/2023		07/10/2024	07/10/2024
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	10/13/2023	01/01/2024			01/01/2024
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	10/13/2023	01/01/2024			01/01/2024
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	10/13/2023	01/01/2024			01/01/2024
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	10/13/2023	01/01/2024			01/01/2024
Contract Detail	FAIRVIEW SPECIALTY SERVICES PHARMACY	711 KASOTA AVENUE SE, SUITE A		MINNEAPOLIS	MN	55414	04/10/2023	07/01/2023			07/01/2023
Contract Detail	GRAND ST. PAUL CVS, L.L.C.	DBA CVS/PHARMACY #10252	1411 VERMILLION STREET	HASTINGS	MN	55033	10/11/2023	01/01/2024			01/01/2024
Contract Detail	GRAND ST. PAUL CVS, L.L.C.	CVS PHARMACY # 17138	1750 ROBERT ST S	WEST ST PAUL	MN	55118	10/11/2023	01/01/2024			01/01/2024
Contract Detail	GRAND ST. PAUL CVS, L.L.C.	DBA: CVS/PHARMACY # 05161	1040 GRAND AVE.	SAINT PAUL	MN	55105	10/11/2023	01/01/2024			01/01/2024
Contract Detail	GRAND ST. PAUL CVS, L.L.C.	DBA: CVS/PHARMACY # 03313	1471 ROBERT STREET S	WEST SAINT PAUL	MN	55118	10/11/2023	01/01/2024			01/01/2024
Contract Detail	GRAND ST. PAUL CVS, L.L.C.	CVS PHARMACY # 16189	8655 E POINT DOUGLAS RD S	COTTAGE GROVE	MN	55016	10/11/2023	01/01/2024			01/01/2024
Contract Detail	GRAND ST. PAUL CVS, L.L.C.	DBA CVS/PHARMACY #10902	30 FAIRVIEW AVE S	SAINT PAUL	MN	55105	10/11/2023	01/01/2024			01/01/2024
Contract Detail	GRAND ST. PAUL CVS, L.L.C.	CVS PHARMACY # 17549	7841 AMANA TRAIL	INVER GROVE HEIGHTS	MN	55077	10/11/2023	01/01/2024			01/01/2024
Contract Detail	MERCY HOSPITAL PHC	4050 COON RAPIDS BLVD NW		COON RAPIDS	MN	55433-2522	01/20/2017	04/01/2017			01/20/2017
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	10/07/2022	01/01/2023		01/03/2023	01/04/2023
Contract Detail	OPTUM PHARMACY 700, LLC	19 CHAPIN RD BLDG D, STE D8		PINE BROOK	NJ	07058	04/10/2023	07/01/2023			07/01/2023
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/10/2023	07/01/2023			07/01/2023
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/11/2023	01/01/2024			01/01/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/10/2023	07/01/2023			07/01/2023
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	04/10/2023	07/01/2023			07/01/2023
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/10/2023	07/01/2023			07/01/2023
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	04/10/2023	07/01/2023			07/01/2023
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/11/2023	01/01/2024			01/01/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/11/2023	01/01/2024			01/01/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/11/2023	01/01/2024			01/01/2024
Contract Detail	SINA DRUG LLC	DBA ONCO360	7125 JANES AVE STE 700	WOODRIDGE	IL	60517	10/07/2022	01/01/2023			01/01/2023
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	10/07/2022	01/01/2023			01/01/2023
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	01/04/2023	04/01/2023			04/01/2023
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/11/2023	01/01/2024			01/01/2024
Contract Detail	WAL-MART PHARMACY 10-1472	1752 NO. FRONTAGE		HASTINGS	MN	55033	10/11/2023	01/01/2024			01/01/2024
Contract Detail	WAL-MART PHARMACY 10-3364	1644 SOUTH ROBERT STREET SOUTH		WEST ST.PAUL	MN	55118	10/11/2023	01/01/2024			01/01/2024
Contract Detail	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	10/11/2023	01/01/2024			01/01/2024
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/11/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05048	1017 VERMILLION ST	HASTINGS	MN	55033	10/05/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03122	985 GENEVA AVENUE N	OAKDALE	MN	55128	10/05/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02805	1133 S ROBERT ST	WEST ST PAUL	MN	55118	10/05/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06056	1965 DONEGAL DR	WOODBURY	MN	55125-4870	10/05/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06057	7135 E POINT DOUGLAS RD SOUTH	COTTAGE GROVE	MN	55016	10/05/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	WALGREENS #11764	790 N PLAZA DR	MENDOTA HEIGHTS	MN	55120-1509	10/05/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09795	1585 RANDOLPH AVE	ST PAUL	MN	55105-2149	10/05/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS SPECIALTY PHARMACY #11916	1221 W LAKE ST, STE 200	MINNEAPOLIS	MN	55408	10/05/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06943	4560 S ROBERT TRAIL	INVER GROVE HEIGHTS	MN	55077	10/05/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04882	5825 CAHILL AVE.	INVER GROVE HEIGHTS	MN	55076	10/05/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15272	1110 LARPENTEUR AVE W	ST PAUL	MN	55113	10/06/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15121	141 CARMICHAEL RD.	HUDSON	WI	54016	10/06/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	COMMUNITY, A WALGREENS PHARMACY #16522	360 SHERMAN ST. SUITE 100	SAINT PAUL	MN	55102	10/06/2023	01/01/2024		04/16/2024	04/16/2024
Contract Detail	WALGREEN CO.	DBA:WALGREENS #13690	2099 FORD PARKWAY	ST. PAUL	MN	55116	10/06/2023	01/01/2024			01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13685	2635 RICE ST	ROSEVILLE	MN	55113	10/06/2023	01/01/2024			01/01/2024
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	10/06/2023	01/01/2024			01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/06/2023	01/01/2024			01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/06/2023	01/01/2024			01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/06/2023	01/01/2024			01/01/2024
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	10/06/2023	01/01/2024			01/01/2024
Contract Detail	WALMART PHARMACY 10-2448	9300 EAST POINT DOUGLAS RD S		COTTAGE GROVE	MN	55016	10/11/2023	01/01/2024			01/01/2024
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/11/2023	01/01/2024			01/01/2024
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/11/2023	01/01/2024			01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH240038AA	Child	DSH	United Hospital	United Hospital - Hastings Regina Campus - Sleep Studies	1285 Nininger Rd	Hastings	MN	Active
DSH240038AB	Child	DSH	United Hospital	United Hospital - Hastings Regina Campus - Medical Imaging	1175 Nininger Rd	Hastings	MN	Active
DSH240038AC	Child	DSH	United Hospital	United Hospital - Hastings Regina Campus - Cardiac Rehabilitation	1175 Nininger Rd	Hastings	MN	Active
DSH240038AD	Child	DSH	United Hospital	United Hospital - Hastings Regina Campus - Regina Pain Center	1175 Nininger Rd	Hastings	MN	Active
DSH240038AE	Child	DSH	United Hospital	United Hospital - Hastings Regina Campus - Emergency Room	1175 Nininger Rd	Hastings	MN	Active
DSH240038AF	Child	DSH	United Hospital	Courage Kenny Sports & Physical Therapy - Hastings YMCA - PT	85 Pleasant Dr	Hastings	MN	Active
DSH240038AG	Child	DSH	United Hospital	Courage Kenny Rehabilitation Institute - Hastings - Nininger Road - PT	1285 Nininger Rd	Hastings	MN	Active
DSH240038AH	Child	DSH	United Hospital	United Hospital - Hastings Regina Campus - Medical Surgical Unit	1175 Nininger Rd	Hastings	MN	Active
DSH240038AJ	Child	DSH	United Hospital	United Hospital - Hastings Regina Campus - Surgical Services	1175 Nininger Rd	Hastings	MN	Active
DSH240038AK	Child	DSH	United Hospital	Allina Health Mental Health - United Regina Hastings Clinic - OP Mental Health	1285 Nininger Rd	Hastings	MN	Active
DSH240038B	Child	DSH	United Hospital	Day Surgery Center	310 North Smith Ave	St Paul	MN	Active
DSH240038C	Child	DSH	United Hospital	Allina Health Minneapolis Heart Institute - United Hospital	225 North Smith Avenue	St Paul	MN	Active
DSH240038D	Child	DSH	United Hospital	Nasseff Heart Center - Spine/PC/MH	255 North Smith	St Paul	MN	Active
DSH240038E	Child	DSH	United Hospital	United Non-Invasive Cardiology (Nasseff Heart Center - PT/Rehab/MH)	255 North Smith Avenue	St Paul	MN	Active
DSH240038F	Child	DSH	United Hospital	Minnesota Perinatal Physicians - United	347 North Smith Avenue	Saint Paul	MN	Active
DSH240038G	Child	DSH	United Hospital	Minnesota Perinatal Physicians - Woodbury	1625 Radio Drive	Woodbury	MN	Active
DSH240038H	Child	DSH	United Hospital	Apple Valley Medical Imaging	14655 Galaxie Avenue	Apple Valley	MN	Terminated
DSH240038J	Child	DSH	United Hospital	United Sleep Center	255 North Smith Avenue	St Paul	MN	Terminated
DSH240038K	Child	DSH	United Hospital	Allina Health Cancer Institute - Piper Breast St. Paul	310 North Smith Avenue	St Paul	MN	Active
DSH240038L	Child	DSH	United Hospital	United Pain Management Clinic	255 North Smith Avenue	St Paul	MN	Active
DSH240038M	Child	DSH	United Hospital	Courage Kenny Rehab Associates (Sister Kenny Rehab Associates)	280 North Smith Avenue	St Paul	MN	Active
DSH240038N	Child	DSH	United Hospital	Courage Kenny Sports & Physical Therapy - Apple Valley	14655 Galaxie Avenue	Apple Valley	MN	Active
DSH240038P	Child	DSH	United Hospital	Allina Health Minneapolis Heart Institute - St. Paul Vascular Clinic	225 North Smith Avenue	St. Paul	MN	Active
DSH240038Q	Child	DSH	United Hospital	Allina Health Mental Health - United Clinic	280 Smith Avenue N	Saint Paul	MN	Active
DSH240038R	Child	DSH	United Hospital	Allina Health Minneapolis Heart Institute - St. Paul Vascular Imaging, CT/Nuc Med, Echo, Stress, Holter and ACT Monitors	225 Smith Ave N	St Paul	MN	Terminated
DSH240038S	Child	DSH	United Hospital	Allina Health Mental Health - United Clinic - OP MH,Adult Partial,Adol Partial	280 Smith Ave N	St Paul	MN	Terminated
DSH240038T	Child	DSH	United Hospital	United Infusion Therapy Center - Infusion	333 Smith Ave N	St Paul	MN	Active
DSH240038U	Child	DSH	United Hospital	Allina Health Cancer Institute - Saint Paul	225 Smith Avenue N	St Paul	MN	Active
DSH240038V	Child	DSH	United Hospital	United Neonatal - Neonatal	333 Smith Ave N	St Paul	MN	Active
DSH240038W	Child	DSH	United Hospital	Allina Health Cancer Institute - United Radiation Oncology - Oncology	310 Smith Ave N	St. Paul	MN	Active
DSH240038X	Child	DSH	United Hospital	Allina Health Cancer Institute - United Hospital, Hastings Cancer Center - Infusion	1175 Nininger Rd	Hastings	MN	Active
DSH240038Y	Child	DSH	United Hospital	Allina Health Cancer Institute - United Hospital, Hastings Clinic - Infusion	1175 Nininger Rd	Hastings	MN	Active
DSH240038Z	Child	DSH	United Hospital	United Hospital - Hastings Regina Campus - Respiratory Therapy	1175 Nininger Rd	Hastings	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 11:24:55 AM	8/12/2024 5:47:36 PM	8/12/2024 5:47 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1316901333	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700840097	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1295799518	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1780648964	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1598822686	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760446124	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1942264270	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1780094698	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1063449213	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1699739045	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1851355135	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104880384	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1982641346	6/17/2024 2:04 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:04 PM
Details	Last Recertification Date	Update	Recertification	9/5/2022 9:30:42 AM	8/16/2023 11:24:55 AM	8/16/2023 11:24 AM
Details	Last Recertification Date	Update	Recertification	9/10/2021 9:11:19 AM	9/5/2022 9:30:42 AM	9/5/2022 9:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		061214600	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		140198000	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		197132000	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		314322800	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		403485000	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		844998000	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		952657900	7/11/2022 1:36 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:36 PM
Addresses	Shipping Address	Insert	Change Request		United Hospital Pharmacy 333 North Smith Ave St. Paul, MN 55102	5/19/2022 7:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		281747100	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		844998000	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		952657900	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		403485000	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		061214600	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		314322800	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		197132000	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		140198000	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		281747101	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MN	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		281747101	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		281747102	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MN	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		281747102	4/12/2022 8:57 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1457319485	4/12/2022 8:57 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760440713	4/12/2022 8:57 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	4/12/2022 8:57 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760440713	4/12/2022 8:57 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1174581151	4/12/2022 8:57 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	4/12/2022 8:57 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1174581151	4/12/2022 8:57 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	4/12/2022 8:57 AM
Contacts	Authorizing Official	Update	Change Request	Collins-Kwong, Tony Director, Strategic Sourcing and Services, Pharmacy Services Allina Health 6122624785	Collins-Kwong, Tony M Director, Strategic Sourcing and Services, Pharmacy Services Allina Health 6122624785	3/22/2022 11:12 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	281747100 (WI)		1/13/2022 3:12 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1457319485 (WI)		1/13/2022 3:12 PM
Contacts	Authorizing Official	Update	Change Request	Krolik, Phillip J. VP, Finance Allina Health 6512418827	Collins-Kwong, Tony Director, Strategic Sourcing and Services, Pharmacy Services Allina Health 6122624785	9/13/2021 12:10 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	281747100 (IA)		9/10/2021 9:11 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	281747100 (ND)		9/10/2021 9:11 AM
Contacts	Primary Contact	Update	Recertification	Collins-Kwong, Tony Director, Strategic Sourcing and Services, Pharmacy Services Allina Health 6122624785	Enger, Jeremy 340B Program Manager Allina Health 6127607836	9/10/2021 9:11 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 3:23:20 PM	9/10/2021 9:11:19 AM	9/10/2021 9:11 AM
Contacts	Primary Contact	Update	Profile Change Request	Collins-Kwong, Tony Pharmacy Services Portfolio Manager Allina Health 6122624785	Collins-Kwong, Tony Director, Strategic Sourcing and Services, Pharmacy Services Allina Health 6122624785	8/23/2021 8:02 AM
Medicaid Billing	Medicaid: Number	Update		281747100	281747100	12/10/2020 4:18 PM
Medicaid Billing	Medicaid: Number	Update		281747100	281747100	12/10/2020 4:18 PM
Medicaid Billing	Medicaid: Number	Update		281747100	281747100	12/10/2020 4:18 PM
Medicaid Billing	Medicaid: Number	Update		281747100	281747100	12/10/2020 4:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457319485	9/1/2020 3:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/1/2020 3:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457319485	9/1/2020 3:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/1/2020 3:23 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1457319485 ( )		9/1/2020 3:23 PM
Details	Last Recertification Date	Update	Recertification	8/22/2019 5:28:45 AM	9/1/2020 3:23:20 PM	9/1/2020 3:23 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 1:15:36 PM	8/22/2019 5:28:45 AM	8/22/2019 5:28 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	281747100 (SD)		3/28/2019 3:17 PM
Details	Last Recertification Date	Update	Recertification	11/8/2017 12:47:10 PM	8/22/2018 1:15:36 PM	8/22/2018 1:15 PM
Contacts	Primary Contact	Update	Change Request	Grunder, Kristy Director, Finance United Hospital 6512418495	Collins-Kwong, Tony Pharmacy Services Portfolio Manager Allina Health 6122624785	7/9/2018 12:51 PM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/8/2017 12:47:10 PM	11/8/2017 12:47 PM
Contacts	Primary Contact	Update	Recertification	Grunder, Kristy Director, Finance 6512418495	Grunder, Kristy Director, Finance United Hospital 6512418495	11/6/2017 4:36 PM
Contacts	Authorizing Official	Update		Krolik, Phillip J. VP, Finance 6512418827	Krolik, Phillip J. VP, Finance Allina Health 6512418827	10/25/2017 9:22 AM
Contacts	Signed By	Insert			Bien, John P. CFO 6512418827	7/12/2017 9:23 AM
Contacts	Primary Contact	Update		Gersema, Lisa Director, Pharmacy 6512418879	Grunder, Kristy Director, Finance 6512418495	7/12/2017 9:23 AM
Contacts	Authorizing Official	Insert			Krolik, Phillip J. VP, Finance 6512418827	7/12/2017 9:23 AM
Addresses	Main Address	Insert			333 North Smith Ave St Paul, MN 55102	7/12/2017 8:57 AM
Contacts	Primary Contact	Insert			Gersema, Lisa Director, Pharmacy 6512418879	9/6/2016 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/5/2016 6:03 PM
Medicaid Billing	Medicaid: Number	Insert			281747100	9/5/2016 6:03 PM
Medicaid Billing	Medicaid: State	Insert			IA	9/5/2016 6:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/5/2016 6:03 PM
Medicaid Billing	Medicaid: Number	Insert			281747100	9/5/2016 6:03 PM
Medicaid Billing	Medicaid: State	Insert			ND	9/5/2016 6:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/5/2016 6:03 PM
Medicaid Billing	Medicaid: Number	Insert			281747100	9/5/2016 6:03 PM
Medicaid Billing	Medicaid: State	Insert			SD	9/5/2016 6:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/5/2016 6:03 PM
Medicaid Billing	Medicaid: Number	Insert			281747100	9/5/2016 6:03 PM
Medicaid Billing	Medicaid: State	Insert			WI	9/5/2016 6:03 PM
Details	Last Recertification Date	Update		8/27/2015 12:00:00 AM	9/1/2016 12:00:00 AM	9/1/2016 2:57 PM
Details	Last Recertification Date	Update		8/25/2014 12:00:00 AM	8/27/2015 12:00:00 AM	9/2/2015 10:30 AM
Details	Last Recertification Date	Update			8/25/2014 12:00:00 AM	8/25/2014 10:49 AM
Dates	Participating Approval Date	Update		9/17/2012 12:00:00 AM	9/15/2013 12:00:00 AM	9/16/2013 4:33 PM
Dates	Signed By Date	Update		8/30/2012 12:00:00 AM	7/2/2013 12:00:00 AM	9/16/2013 4:33 PM
Details	State	Update		Terminated	Active	9/15/2013 2:43 AM
Dates	Start Date	Update		10/1/2012 12:00:00 AM	10/1/2013 12:00:00 AM	9/15/2013 2:43 AM
Terminations	Termination Date	Update		7/1/2013 12:00:00 AM		9/15/2013 2:43 AM
Terminations	Termination Reason	Update		DSH percentage below statutory minimum		9/15/2013 2:43 AM
Details	Comments Public	Insert			9/15/13 Enrolled 10/1/2012 and terminated 7/1/2013 due to a reported DSH percentage below the statutory minimum. Ineligible from 7/1/2013 through 9/30/2013; reinstated effective 10/1/2013.	9/15/2013 2:43 AM
Details	State	Update		Active	Terminated	6/28/2013 1:09 PM
Terminations	Termination Date	Update			7/1/2013 12:00:00 AM	6/28/2013 1:09 PM
Terminations	Termination Reason	Update			DSH percentage below statutory minimum	6/28/2013 1:09 PM
Details	340B ID	Update		IS-DR-DSH240038	DSH240038	9/17/2012 12:34 PM
Dates	Participating Approval Date	Update			9/17/2012 12:00:00 AM	9/17/2012 12:34 PM
Details	State	Update		Pending	Active	9/17/2012 12:34 PM
Dates	Start Date	Update			10/1/2012 12:00:00 AM	9/17/2012 12:34 PM
Details	340B ID	Update		DR-DSH240038	IS-DR-DSH240038	9/12/2012 3:27 PM
Details	340B ID	Update		DR083112H	DR-DSH240038	9/6/2012 12:03 PM
Details	340B ID	Update		ONLINE_REG	DR083112H	8/31/2012 5:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/30/2012 2:22 PM
Medicaid Billing	Medicaid: Number	Insert			281747100	8/30/2012 2:22 PM
Medicaid Billing	Medicaid: State	Insert			MN	8/30/2012 2:22 PM
Medicaid Billing	NPI: Number	Insert			1457319485	8/30/2012 2:22 PM
Details	Last Recertification Date	Insert				8/30/2012 2:22 PM
Details	Grant Number	Insert				8/30/2012 2:22 PM
Details	340B ID	Insert			ONLINE_REG	8/30/2012 2:22 PM
Details	Is Authorizing Official EHB Data	Insert				8/30/2012 2:22 PM
Dates	Last Date That 340B Drugs Purchased	Insert				8/30/2012 2:22 PM
Details	Medicare Provider Number	Insert			240038	8/30/2012 2:22 PM
Details	Entity Name	Insert			United Hospital	8/30/2012 2:22 PM
Details	Program Code	Insert			DSH	8/30/2012 2:22 PM
Details	Entity Subname	Insert				8/30/2012 2:22 PM
Dates	Participating Approval Date	Insert				8/30/2012 2:22 PM
Details	State	Insert			Pending	8/30/2012 2:22 PM
Dates	Registration Date	Insert			8/30/2012 12:00:00 AM	8/30/2012 2:22 PM
Dates	Signed By Date	Insert			8/30/2012 12:00:00 AM	8/30/2012 2:22 PM
Dates	Start Date	Insert				8/30/2012 2:22 PM
Terminations	Termination Comments	Insert				8/30/2012 2:22 PM
Terminations	Termination Date	Insert				8/30/2012 2:22 PM
Terminations	Termination Effective Date	Insert				8/30/2012 2:22 PM
Terminations	Termination Reason	Insert				8/30/2012 2:22 PM