Covered Entity Details

DSH240038N United Hospital (Active) - information as of 5/26/2025 12:57:04 AM

Main Details

Name

United Hospital

Subdivision Name

Courage Kenny Sports & Physical Therapy - Apple Valley

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240038N

Medicare Provider Number

240038

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/2/2013

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

14655 Galaxie Avenue
160
Apple Valley, MN 55124-8575

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	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

Same as Street Address

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	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	03/28/2024	04/01/2024	04/01/2024		04/01/2024
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	03/28/2024	04/01/2024	04/01/2024		04/01/2024
Contract Detail	ALLINA HEALTH NEW ULM PHARMACY	1217 8TH ST N STE 1010		NEW ULM	MN	56073-1552	03/28/2024	04/01/2024	04/01/2024		04/01/2024
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 RITCHIE PHARMACY		280 NORTH SMITH AVE SUITE 120	ST PAUL	MN	55102	10/14/2013	01/01/2014		04/14/2021	04/14/2021
Contract Detail	ALLINA HEALTH ST. FRANCIS PHARMACY	1455 SAINT FRANCIS AVE STE 100		SHAKOPEE	MN	55379-3374	03/28/2024	04/01/2024	04/01/2024		04/01/2024
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	12/01/2023	01/01/2024			01/01/2024
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	MERCY HOSPITAL PHC	4050 COON RAPIDS BLVD NW		COON RAPIDS	MN	55433-2522	01/20/2017	04/01/2017			01/20/2017

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 11:15:31 AM	8/12/2024 5:50:12 PM	8/12/2024 5:50 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	9/2/2022 3:14:28 PM	8/16/2023 11:15:31 AM	8/16/2023 11:15 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 12:13:45 PM	9/2/2022 3:14:28 PM	9/2/2022 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		061214600	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		140198000	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		197132000	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		314322800	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		403485000	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		844998000	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		952657900	7/11/2022 1:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/11/2022 1:39 PM
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
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	9/9/2021 12:13 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 7:48:54 AM	9/9/2021 12:13:45 PM	9/9/2021 12:13 PM
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
Addresses	Main Address	Update	Recertification	14655 Galaxie Avenue Apple Valley, MN 55124	14655 Galaxie Avenue 160 Apple Valley, MN 55124-8575	9/10/2020 7:48 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	281747100 (IA)		9/10/2020 7:48 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	281747100 (SD)		9/10/2020 7:48 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	281747100 (ND)		9/10/2020 7:48 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1457319485 ( )		9/10/2020 7:48 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1457319485	9/10/2020 7:48 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/10/2020 7:48 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1457319485	9/10/2020 7:48 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/10/2020 7:48 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 3:47:46 PM	9/10/2020 7:48:54 AM	9/10/2020 7:48 AM
Details	Entity Subname	Update	Recertification	Courage Kenny Rehab Institute Apple Valley	Courage Kenny Sports & Physical Therapy - Apple Valley	9/10/2020 7:48 AM
Details	Last Recertification Date	Update	Recertification	8/16/2018 4:00:56 PM	8/20/2019 3:47:46 PM	8/20/2019 3:47 PM
Contacts	Primary Contact	Update	Change Request	Grunder, Kristy Director, Finance United Hospital 6512418495	Collins-Kwong, Tony Pharmacy Services Portfolio Manager Allina Health 6122624785	4/23/2019 8:09 AM
Details	Last Recertification Date	Update	Recertification	11/6/2017 4:41:28 PM	8/16/2018 4:00:56 PM	8/16/2018 4:00 PM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/6/2017 4:41:28 PM	11/6/2017 4:41 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			14655 Galaxie Avenue Apple Valley, MN 55124	7/12/2017 9:23 AM
Contacts	Primary Contact	Insert			Gersema, Lisa Director, Pharmacy 6512418879	9/6/2016 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/1/2016 2:57 PM
Medicaid Billing	Medicaid: Number	Insert			281747100	9/1/2016 2:57 PM
Medicaid Billing	Medicaid: State	Insert			IA	9/1/2016 2:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/1/2016 2:57 PM
Medicaid Billing	Medicaid: Number	Insert			281747100	9/1/2016 2:57 PM
Medicaid Billing	Medicaid: State	Insert			WI	9/1/2016 2:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/1/2016 2:57 PM
Medicaid Billing	Medicaid: Number	Insert			281747100	9/1/2016 2:57 PM
Medicaid Billing	Medicaid: State	Insert			SD	9/1/2016 2:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/1/2016 2:57 PM
Medicaid Billing	Medicaid: Number	Insert			281747100	9/1/2016 2:57 PM
Medicaid Billing	Medicaid: State	Insert			ND	9/1/2016 2:57 PM
Details	Last Recertification Date	Update		9/2/2015 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	9/2/2015 12:00:00 AM	9/2/2015 11:55 AM
Details	Entity Subname	Update		Sister Kenny Rehab Institute Apple Valley	Courage Kenny Rehab Institute Apple Valley	9/2/2015 11:55 AM
Details	Last Recertification Date	Update			8/25/2014 12:00:00 AM	8/25/2014 10:49 AM
Dates	Participating Approval Date	Update			9/15/2013 12:00:00 AM	9/15/2013 3:11 AM
Details	State	Update		Pending	Active	9/15/2013 3:11 AM
Dates	Start Date	Update			10/1/2013 12:00:00 AM	9/15/2013 3:11 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH240038N	8/2/2013 3:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/2/2013 1:16 PM
Medicaid Billing	Medicaid: Number	Insert			281747100	7/2/2013 1:16 PM
Medicaid Billing	Medicaid: State	Insert			MN	7/2/2013 1:16 PM
Medicaid Billing	NPI: Number	Insert			1457319485	7/2/2013 1:16 PM
Details	Last Recertification Date	Insert				7/2/2013 1:16 PM
Details	Grant Number	Insert				7/2/2013 1:16 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	7/2/2013 1:16 PM
Details	Is Authorizing Official EHB Data	Insert				7/2/2013 1:16 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/2/2013 1:16 PM
Details	Medicare Provider Number	Insert			240038	7/2/2013 1:16 PM
Details	Entity Name	Insert			United Hospital	7/2/2013 1:16 PM
Details	Program Code	Insert			DSH	7/2/2013 1:16 PM
Details	Entity Subname	Insert			Sister Kenny Rehab Institute Apple Valley	7/2/2013 1:16 PM
Dates	Participating Approval Date	Insert				7/2/2013 1:16 PM
Details	State	Insert			Pending	7/2/2013 1:16 PM
Dates	Registration Date	Insert			7/2/2013 12:00:00 AM	7/2/2013 1:16 PM
Dates	Signed By Date	Insert			7/2/2013 12:00:00 AM	7/2/2013 1:16 PM
Dates	Start Date	Insert				7/2/2013 1:16 PM
Terminations	Termination Comments	Insert				7/2/2013 1:16 PM
Terminations	Termination Date	Insert				7/2/2013 1:16 PM
Terminations	Termination Effective Date	Insert				7/2/2013 1:16 PM
Terminations	Termination Reason	Insert				7/2/2013 1:16 PM