Covered Entity Details

DSH240001 North Memorial Health Care (Active) - information as of 6/9/2025 10:55:19 PM

Main Details

Name

North Memorial Health Care

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240001

Medicare Provider Number

240001

Additional Details

Current Program Status

Active

Registration Date

10/12/2012

Participating Start Date

1/1/2013

Participating Approval Date

10/26/2012

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Maple Grove Hospital
Trevor Sawallish, CEO
(763) 581-4721

Primary Contact

North Memorial Health
Barbara Hintzen, Pharmacy Program Manager
(763) 581-2099

Addresses

Street Address

3300 Oakdale Ave North
Robbinsdale, MN 55422

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	777545800,179217200	1437297207,1851344907,1093905259,1841995552

Shipping Addresses

Shipping Address 1

North Memorial Medical Center
3300 Oakdale Ave North
Robbinsdale, MN 55422

Shipping Address 2

North Memorial Hubert Humphrey Cancer Center
3435 West Broadway Suite 1135
Robbinsdale, MN 55422

Shipping Address 3

North Memorial Maple Grove Outpatient Pharmacy
9825 Hospital Drive, Suite 100
Maple Grove, MN 55369

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 HOME INFUSION	711 B KASOTA AVENUE SE		MINNEAPOLIS	MN	55414	04/13/2018	07/01/2018			04/13/2018
Contract Detail	FAIRVIEW SPECIALTY SERVICES PHARMACY	711 KASOTA AVENUE SE, SUITE A		MINNEAPOLIS	MN	55414	01/15/2018	04/01/2018			01/15/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH240001A	Child	DSH	North Memorial Health Care	Breast Center	3366 Oakdale Ave N. Suite LL	Robbinsdale	MN	Active
DSH240001B	Child	DSH	North Memorial Health Care	Hospice Care	3500 France Ave N	Robbinsdale	MN	Active
DSH240001C	Child	DSH	North Memorial Health Care	OP CT	Outpatient Imaging Center	Robbinsdale	MN	Active
DSH240001D	Child	DSH	North Memorial Health Care	OP MRI	Outpatient Imaging Center	Robbinsdale	MN	Active
DSH240001E	Child	DSH	North Memorial Health Care	OP PET	Outpatient Imaging Center	Robbinsdale	MN	Active
DSH240001F	Child	DSH	North Memorial Health Care	OP Nuclear Medicine	Outpatient Imaging Center	Robbinsdale	MN	Active
DSH240001G	Child	DSH	North Memorial Health Care	Sleep Lab MG	13800 83rd Way N	Maple Grove	MN	Terminated
DSH240001H	Child	DSH	North Memorial Health Care	Sleep Lab NM	Oakdale Medical Building	Robbinsdale	MN	Terminated
DSH240001J	Child	DSH	North Memorial Health Care	Partial Hospital Program	Outpatient Psychiatric Clinic	Robbinsdale	MN	Terminated
DSH240001K	Child	DSH	North Memorial Health Care	HUBERT H HUMPHREY CANCER CTR	3435 WEST BROADWAY	ROBBINSDALE	MN	Active
DSH240001L	Child	DSH	North Memorial Health Care	NORTH MEMORIAL CARDIOVASCULAR SERVICES	15450 HIGHWAY 7 225	MINNETONKA	MN	Terminated
DSH240001M	Child	DSH	North Memorial Health Care	N MEM CARDIOVASCULAR SERVICES	9825 HOSPITAL DRIVE	MAPLE GROVE	MN	Terminated
DSH240001N	Child	DSH	North Memorial Health Care	NORTH MEMORIAL RHEUMATOLOGYBLAINE - Rheumatology	4181 108TH AVE NE	BLAINE	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Hintzen, Barbara Pharmacy Program Supervisor North Memorial Health 7635812099	Hintzen, Barbara Pharmacy Program Manager North Memorial Health 7635812099	6/5/2025 3:02 PM
Details	Last Recertification Date	Update	Recertification	8/24/2023 5:32:53 PM	9/3/2024 1:00:26 PM	9/3/2024 1:00 PM
Contacts	Primary Contact	Update	Change Request	Krogh, Paul R Director, Pharmacy North Memorial Health 7635812129	Hintzen, Barbara Pharmacy Program Supervisor North Memorial Health 7635812099	4/3/2024 2:03 PM
Contacts	Authorizing Official	Update	Change Request	Croston, Kevin J. CEO North Memorial Health 7635814702	Sawallish, Trevor CEO Maple Grove Hospital 7635814721	4/3/2024 2:03 PM
Details	Last Recertification Date	Update	Recertification	9/7/2022 11:07:05 AM	8/24/2023 5:32:53 PM	8/24/2023 5:32 PM
Addresses	Shipping Address	Insert	Change Request		North Memorial Maple Grove Outpatient Pharmacy 9825 Hospital Drive, Suite 100 Maple Grove, MN 55369	4/10/2023 3:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841995552	4/10/2023 3:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	4/10/2023 3:18 PM
Details	Last Recertification Date	Update	Recertification	8/24/2021 12:33:31 PM	9/7/2022 11:07:05 AM	9/7/2022 11:07 AM
Details	Last Recertification Date	Update	Recertification	8/24/2020 1:43:50 PM	8/24/2021 12:33:31 PM	8/24/2021 12:33 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1437297207 ( )		8/24/2020 1:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1437297207	8/24/2020 1:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	8/24/2020 1:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1851344907	8/24/2020 1:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	8/24/2020 1:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1093905259	8/24/2020 1:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	8/24/2020 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1851344907 ( )		8/24/2020 1:43 PM
Details	Last Recertification Date	Update	Recertification	8/28/2019 10:13:24 AM	8/24/2020 1:43:50 PM	8/24/2020 1:43 PM
Details	Last Recertification Date	Update	Recertification	8/31/2018 7:55:01 AM	8/28/2019 10:13:24 AM	8/28/2019 10:13 AM
Addresses	Shipping Address	Insert	Change Request		North Memorial Hubert Humphrey Cancer Center 3435 West Broadway Suite 1135 Robbinsdale, MN 55422	4/2/2019 7:03 AM
Details	Last Recertification Date	Update	Recertification	11/16/2017 1:22:54 PM	8/31/2018 7:55:01 AM	8/31/2018 7:55 AM
Details	Last Recertification Date	Update	Recertification	8/15/2016 12:00:00 AM	11/16/2017 1:22:54 PM	11/16/2017 1:22 PM
Contacts	Authorizing Official	Update		Croston, Kevin J. CEO 7635814702	Croston, Kevin J. CEO North Memorial Health 7635814702	11/16/2017 1:13 PM
Contacts	Primary Contact	Update		Krogh, Paul Director, Pharmacy 7635812129	Krogh, Paul R Director, Pharmacy North Memorial Health 7635812129	10/10/2017 3:02 PM
Contacts	Authorizing Official	Insert			Croston, Kevin J. CEO 7635814702	8/16/2016 8:15 AM
Contacts	Primary Contact	Update		Kaufenberg, Tony Director of Pharmacy 7635205854	Krogh, Paul Director, Pharmacy 7635812129	8/16/2016 8:15 AM
Addresses	Main Address	Insert			3300 Oakdale Ave North Robbinsdale, MN 55422	8/15/2016 11:08 AM
Contacts	Signed By	Insert			Boran, Patrick J. Vice President of Finance/CFO 7635814562	8/15/2016 11:08 AM
Details	Last Recertification Date	Update		8/11/2015 12:00:00 AM	8/15/2016 12:00:00 AM	8/15/2016 11:08 AM
Addresses	Shipping Address	Insert			North Memorial Medical Center 3300 Oakdale Ave North Robbinsdale, MN 55422	7/21/2016 12:00 PM
Details	Last Recertification Date	Update		8/20/2014 12:00:00 AM	8/11/2015 12:00:00 AM	8/11/2015 12:56 PM
Details	Last Recertification Date	Update		8/29/2013 12:00:00 AM	8/20/2014 12:00:00 AM	8/20/2014 1:57 PM
Details	Last Recertification Date	Update			8/29/2013 12:00:00 AM	8/29/2013 10:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/21/2013 3:49 PM
Medicaid Billing	Medicaid: Number	Insert			179217200	6/21/2013 3:49 PM
Medicaid Billing	Medicaid: State	Insert			MN	6/21/2013 3:49 PM
Medicaid Billing	NPI: Number	Insert			1437297207	6/21/2013 3:49 PM
Contacts	Primary Contact	Insert			Kaufenberg, Tony Director of Pharmacy 7635205854	12/20/2012 4:12 PM
Details	340B ID	Update		IS-AP-DSH240001	DSH240001	10/26/2012 4:38 PM
Dates	Participating Approval Date	Update			10/26/2012 12:00:00 AM	10/26/2012 4:38 PM
Details	State	Update		Pending	Active	10/26/2012 4:38 PM
Dates	Start Date	Update			1/1/2013 12:00:00 AM	10/26/2012 4:38 PM
Details	340B ID	Update		AP101212F	IS-AP-DSH240001	10/26/2012 1:44 PM
Details	340B ID	Update		ONLINE_REG	AP101212F	10/12/2012 5:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/12/2012 9:23 AM
Medicaid Billing	Medicaid: Number	Insert			777545800	10/12/2012 9:23 AM
Medicaid Billing	Medicaid: State	Insert			MN	10/12/2012 9:23 AM
Medicaid Billing	NPI: Number	Insert			1851344907	10/12/2012 9:23 AM
Details	Last Recertification Date	Insert				10/12/2012 9:23 AM
Details	Grant Number	Insert				10/12/2012 9:23 AM
Details	340B ID	Insert			ONLINE_REG	10/12/2012 9:23 AM
Details	Is Authorizing Official EHB Data	Insert				10/12/2012 9:23 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/12/2012 9:23 AM
Details	Medicare Provider Number	Insert			240001	10/12/2012 9:23 AM
Details	Entity Name	Insert			North Memorial Health Care	10/12/2012 9:23 AM
Details	Program Code	Insert			DSH	10/12/2012 9:23 AM
Details	Entity Subname	Insert				10/12/2012 9:23 AM
Dates	Participating Approval Date	Insert				10/12/2012 9:23 AM
Details	State	Insert			Pending	10/12/2012 9:23 AM
Dates	Registration Date	Insert			10/12/2012 12:00:00 AM	10/12/2012 9:23 AM
Dates	Signed By Date	Insert			10/12/2012 12:00:00 AM	10/12/2012 9:23 AM
Dates	Start Date	Insert				10/12/2012 9:23 AM
Terminations	Termination Comments	Insert				10/12/2012 9:23 AM
Terminations	Termination Date	Insert				10/12/2012 9:23 AM
Terminations	Termination Effective Date	Insert				10/12/2012 9:23 AM
Terminations	Termination Reason	Insert				10/12/2012 9:23 AM