Covered Entity Details

DSH240004H HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER (Terminated) - information as of 6/5/2025 2:43:43 PM

Main Details

Name

HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER

Subdivision Name

HCMC Sr Care at Augustana

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240004H

Medicare Provider Number

240004

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/7/2013

Participating Start Date

1/1/2014

Participating Approval Date

12/13/2013

Last Recertification Date

9/5/2019

Termination Date
Termination Reason

10/1/2020
Site closure

Contacts

Authorizing Official

Hennepin County Medical Center - Hennepin Healthcare Inc
Emily Blomberg, Chief Operating Official
(612) 873-9913

Primary Contact

Hennepin Healthcare Systems, Inc. - HCMC
Christene Marie Jolowsky, Pharmacy Director
(612) 873-9917

Addresses

Street Address

1425 10th Avenue South
Minneapolis, MN 55404

Billing Address

Hennepin Healthcare System, Inc. - Hennepin County Medical Center
701 Park Ave. South
Minneapolis, MN 55415

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	157245800,701906X
		1407897309

Shipping Addresses

Shipping Address 1

Hennepin Healthcare System, Inc. - Hennepin County Medical Center
730 So 8th St
RL Pharmacy
Minneapolis, MN 55415

Shipping Address 2

Hennepin Healthcare System, Inc. - Hennepin County Medical Center
901 South 6th Street
Minneapolis, MN 55415

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
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH240004A	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	WHITTIER CLINIC	2810 NICOLLET AVE.	MINNEAPOLIS	MN	Active
DSH240004AA	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Eye Clinic	715 South 8th Street 4th Floor 410	Minneapolis	MN	Active
DSH240004AB	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Pediatric Clinic	715 South 8th Street 3rd Floor 309 & 310	Minneapolis	MN	Active
DSH240004AC	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Coordinated Care Center	900 South 8th Street Suite S1.300	Minneapolis	MN	Active
DSH240004AD	Child	DSH	HENNEPIN COUNTY MEDICAL CENTER	Medicine Clinic	716 South 7th Street Suite P7	Minneapolis	MN	Terminated
DSH240004AE	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Women's Health and Wellness Clinic and OB/GYN Clinic	715 South 8th Street 5th Floor 504 & 505	Minneapolis	MN	Active
DSH240004AF	Child	DSH	HENNEPIN COUNTY MEDICAL CENTER	Addiction Medicine Clinic	701 PARK AVE	MINNEAPOLIS	MN	Terminated
DSH240004AG	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Sleep Center Clinic	900 South 8th Street Suite G8.220	Minneapolis	MN	Active
DSH240004AH	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Gastroenterology & Liver Clinic	715 South 8th Street 5th Floor 508	Minneapolis	MN	Active
DSH240004AJ	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Diabetes & Endocrinology Care Clinic	715 South 8th Street 2nd Floor 204	Minneapolis	MN	Active
DSH240004AK	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Rheumatology Clinic	715 South 8th Street 2nd Floor 203	Minneapolis	MN	Active
DSH240004AL	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Pulmonary Clinic / Pulmonary Function Lab	715 South 8th Street 2nd Floor 201 & 202	Minneapolis	MN	Active
DSH240004AM	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Dermatology Clinic	715 South 8th Street 3rd Floor 308	Minneapolis	MN	Active
DSH240004AN	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	BE WELL CLINIC - HCMC Be Well Clinic	701 4TH AVE. S, STE. 100	MINNEAPOLIS	MN	Terminated
DSH240004AP	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	GOLDEN VALLEY CLINIC - HCMC - HCMC Golden Valley Clinic	5653 DULUTH STREET	GOLDEN VALLEY	MN	Active
DSH240004AQ	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	RICHFIELD CLINIC - Richfield Clinic	790 W 66TH ST	RICHFIELD	MN	Active
DSH240004AR	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	ST. ANTHONY VILLAGE CLINIC - St. Anthony Village Clinic	2714 Highway 88	St. Anthony	MN	Active
DSH240004AS	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	North Loop Clinic - North Loop Clinic	800 Washington Ave. North	Minneapolis	MN	Active
DSH240004AT	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Echo Cardiography - Echo Cardiography	715 South 8th Street, Level 2	Minneapolis	MN	Active
DSH240004AU	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC EKG Diagnostic Lab - EKG Diagnostic Lab	715 South 8th Street, Level 2	Minneapolis	MN	Active
DSH240004AV	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC EMG Diagnostic Lab - EMG Diagnostic Lab	715 South 8th Street, Level 3	Minneapolis	MN	Active
DSH240004AW	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Integrative Health Clinic - Integrative Health Clinic	715 South 8th Street, Level 3	Minneapolis	MN	Active
DSH240004AX	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Mammography - Mammography	715 South 8th Street, Level 1	Minneapolis	MN	Active
DSH240004AY	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Medicine Clinic - Medicine Clinic	715 South 8 Street, Level 2	Minneapolis	MN	Active
DSH240004AZ	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Occupational Therapy - Occupational Therapy	715 South 8th Street, Level 3	Minneapolis	MN	Active
DSH240004B	Child	DSH	HENNEPIN COUNTY MEDICAL CENTER	Brooklyn Center Clinic	6601 Shingle Creek Parkway	Brooklyn Center	MN	Terminated
DSH240004BA	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Orthopedic Clinic - Orthopedic Clinic	715 South 8th Street, Level 1	Minneapolis	MN	Active
DSH240004BB	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Outpatient Cardiac Rehab - Outpatient Cardiac Rehab	715 South 8th Street, Level 2	Minneapolis	MN	Active
DSH240004BC	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Physical Therapy - Physical Therapy	715 South 8th Street, Level 3	Minneapolis	MN	Active
DSH240004BD	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC PMR and TBI Clinic - PMR and TBI Clinic	715 South 8th Street, Level 3	Minneapolis	MN	Active
DSH240004BE	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Radiation Therapy - Radiation Therapy	715 South 8th Street, Lower Level	Minneapolis	MN	Active
DSH240004BF	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Speech-Language Pathology - Speech-Language Pathology	715 South 8th Street, Level 3	Minneapolis	MN	Active
DSH240004BG	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Surgery Clinic - Surgery Clinic	715 South 8th Street, Level 5	Minneapolis	MN	Active
DSH240004BH	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Ultrasound - Ultrasound	715 South 8th Street, Level 1	Minneapolis	MN	Active
DSH240004BJ	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Senior Care Clinic Parkside - Senior Care Clinic	825 South 8th Street, Suite 440	Minneapolis	MN	Terminated
DSH240004BK	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Operating Room - CSC Operating Room	715 South 8th Street	Minneapolis	MN	Active
DSH240004BL	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Hennepin Healthcare Hospice - Hospice	2000 Summer St. NE	Minneapolis	MN	Terminated
DSH240004BM	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Radiation Therapy - Radiation Oncology	715 South 8th Street Level 1	Minneapolis	MN	Active
DSH240004BN	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Computed Tomography - Computed Tomography Scan	715 South 8th Street Level 1	Minneapolis	MN	Active
DSH240004BP	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC OB Testing Diagnostic Lab - OB Testing Diagnostic Lab	715 South 8th Street Level 5	Minneapolis	MN	Active
DSH240004BQ	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	HCMC Whittier Clinic Speech Language Pathology - Speech Pathology	2810 Nicollet Ave. S	Minneapolis	MN	Active
DSH240004BR	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	HENNEPIN HEALTHCARE SYSTEM INC - Comprehensive Weight Mgmt Ctr	701 PARK AVE	MINNEAPOLIS	MN	Active
DSH240004BS	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Hennepin Healthcare System - Neurosurgery Clinic - CSC Level 3	715 South 8th St - Level 3	Minneapolis	MN	Active
DSH240004BT	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Same Day Access Clinic	715 South 8th Street 203, 208, 209	Minneapolis	MN	Active
DSH240004C	Child	DSH	HENNEPIN COUNTY MEDICAL CENTER	Richfield Clinic	44 West 66th Street	Richfield	MN	Terminated
DSH240004D	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	East Lake Clinic	2215 East Lake Street	Minneapolis	MN	Active
DSH240004E	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Brooklyn Park Clinic	7650 Zane Avenue North	Brooklyn Park	MN	Active
DSH240004F	Child	DSH	HENNEPIN COUNTY MEDICAL CENTER	Neurology and Specialty Clinic	111 Hundertmark Road	Chaska	MN	Terminated
DSH240004H	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	HCMC Sr Care at Augustana	1425 10th Avenue South	Minneapolis	MN	Terminated
DSH240004J	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Dental & Oral Surgery Clinic	715 South 8th Street 4th Floor 408	Minneapolis	MN	Active
DSH240004K	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Transplant Clinic	900 South 8th Street Suite B1.310	Minneapolis	MN	Active
DSH240004L	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Infusion Center	715 South 8th Street 1st Floor A1.820	Minneapolis	MN	Active
DSH240004M	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Urology Clinic	715 South 8th Street 5th Floor 507	Minneapolis	MN	Active
DSH240004N	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Interventional Pain Clinic	715 South 8th Street 5th Floor 510	Minneapolis	MN	Active
DSH240004P	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Internal Medicine Clinic	715 South 8th Street 203, 208 & 209	Minneapolis	MN	Active
DSH240004Q	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Allergy Clinic	715 South 8th Street 1st Floor 108	Minneapolis	MN	Active
DSH240004R	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Addiction Medicine Clinic	914 S. 8th Street	Minneapolis	MN	Active
DSH240004S	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Positive Care Clinic	913 South 7th Street Suite B1.290	Minneapolis	MN	Active
DSH240004T	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Cardiology Clinic	715 South 8th Street 2nd Floor 201 & 202	Minneapolis	MN	Active
DSH240004U	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Cancer Center	715 South 8th Street 1st Floor A1.744	Minneapolis	MN	Active
DSH240004V	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC Neurology Clinic	715 South 8th Street 3rd Floor 301	Minneapolis	MN	Active
DSH240004W	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Chronic Wound Care	716 South 7th Street P1.600	Minneapolis	MN	Active
DSH240004X	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Burn Clinic	716 South 7th Street Suite P4	Minneapolis	MN	Active
DSH240004Y	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	CSC ENT Clinic	715 South 8th Street 3rd Floor 301	Minneapolis	MN	Active
DSH240004Z	Child	DSH	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	Adult Psychiatry Clinic	914 South 8th Street Suite 110	Minneapolis	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/28/2020 12:00:00 AM	7/14/2020 8:34 AM
Details	State	Update	Termination Request	Active	To Be Terminated	7/14/2020 8:34 AM
Terminations	Termination Date	Update	Termination Request		10/1/2020 12:00:00 AM	7/14/2020 8:34 AM
Terminations	Termination Effective Date	Update	Termination Request		2/28/2020 12:00:00 AM	7/14/2020 8:34 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	7/14/2020 8:34 AM
Contacts	Authorizing Official	Update	AO Change Request	Cumming, John Interim CEO Hennepin Healthcare Systems, Inc. - HCMC 6128733000	Blomberg, Emily Chief Operating Official Hennepin County Medical Center - Hennepin Healthcare Inc 6128739913	3/1/2020 8:13 PM
Details	Last Recertification Date	Update	Recertification	8/15/2018 10:33:32 AM	9/5/2019 12:13:58 PM	9/5/2019 12:13 PM
Contacts	Authorizing Official	Update	Change Request	PRYOR, JON L. CEO Hennepin Healthcare System, INC - HCMC 6128733000	Cumming, John Interim CEO Hennepin Healthcare Systems, Inc. - HCMC 6128733000	2/8/2019 9:49 AM
Contacts	Authorizing Official	Update	Profile Change Request	PRYOR, JON L. CEO Hennepin Healthcare System, INC - Hennepin County Medical Center 6128733000	PRYOR, JON L. CEO Hennepin Healthcare System, INC - HCMC 6128733000	8/15/2018 10:44 AM
Contacts	Signed By	Update	Profile Change Request	PRYOR, JON L. CEO Hennepin Healthcare System, INC - Hennepin County Medical Center 6128733000	PRYOR, JON L. CEO Hennepin Healthcare System, INC - HCMC 6128733000	8/15/2018 10:44 AM
Contacts	Authorizing Official	Update	Profile Change Request	PRYOR, JON L. CEO Hennepin County Medical Center 6128733000	PRYOR, JON L. CEO Hennepin Healthcare System, INC - Hennepin County Medical Center 6128733000	8/15/2018 10:43 AM
Contacts	Signed By	Update	Profile Change Request	PRYOR, JON L. CEO Hennepin County Medical Center 6128733000	PRYOR, JON L. CEO Hennepin Healthcare System, INC - Hennepin County Medical Center 6128733000	8/15/2018 10:43 AM
Details	Last Recertification Date	Update	Recertification	11/8/2017 12:46:36 PM	8/15/2018 10:33:32 AM	8/15/2018 10:33 AM
Contacts	Authorizing Official	Update	Profile Change Request	PRYOR, JON L. CEO Hennepin County Medical Center 6128732343	PRYOR, JON L. CEO Hennepin County Medical Center 6128733000	8/15/2018 10:11 AM
Contacts	Signed By	Update	Profile Change Request	PRYOR, JON L. CEO Hennepin County Medical Center 6128732343	PRYOR, JON L. CEO Hennepin County Medical Center 6128733000	8/15/2018 10:11 AM
Details	Entity Name	Update	Change Request	HENNEPIN COUNTY MEDICAL CENTER	HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER	7/27/2018 12:11 PM
Addresses	Shipping Address	Delete	Change Request	Hennepin County Medical Center 901 South 6th Street Minneapolis, MN 55415		7/27/2018 11:41 AM
Addresses	Billing Address	Insert	Change Request		Hennepin Healthcare System, Inc. - Hennepin County Medical Center 701 Park Ave. South Minneapolis, MN 55415	7/27/2018 11:41 AM
Addresses	Shipping Address	Insert	Change Request		Hennepin Healthcare System, Inc. - Hennepin County Medical Center 730 So 8th St RL Pharmacy Minneapolis, MN 55415	7/27/2018 11:41 AM
Addresses	Shipping Address	Insert	Change Request		Hennepin Healthcare System, Inc. - Hennepin County Medical Center 901 South 6th Street Minneapolis, MN 55415	7/27/2018 11:41 AM
Addresses	Shipping Address	Delete	Change Request	Hennepin County Medical Center 730 So 8th St RL Pharmacy Minneapolis, MN 55415		7/27/2018 11:41 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265657746 ( )		7/27/2018 11:41 AM
Contacts	Primary Contact	Update	Change Request	Pitzl, Michael Pharmacy Director Hennepin County Medical Center 6128739917	Jolowsky, Christene Marie Pharmacy Director Hennepin Healthcare Systems, Inc. - HCMC 6128739917	7/27/2018 11:41 AM
Addresses	Shipping Address	Insert	Recertification		Hennepin County Medical Center 901 South 6th Street Minneapolis, MN 55415	11/8/2017 12:46 PM
Details	Last Recertification Date	Update	Recertification	10/25/2017 11:47:52 AM	11/8/2017 12:46:36 PM	11/8/2017 12:46 PM
Details	Last Recertification Date	Update	Recertification	8/16/2016 12:00:00 AM	10/25/2017 11:47:52 AM	10/25/2017 11:47 AM
Contacts	Authorizing Official	Update	New Registration	PRYOR, JON L. CEO 6128732343	PRYOR, JON L. CEO Hennepin County Medical Center 6128732343	10/12/2017 12:46 PM
Contacts	Signed By	Update	New Registration	PRYOR, JON L. CEO 6128732343	PRYOR, JON L. CEO Hennepin County Medical Center 6128732343	10/12/2017 12:46 PM
Contacts	Primary Contact	Update		Pitzl, Michael Pharmacy Director 6128739917	Pitzl, Michael Pharmacy Director Hennepin County Medical Center 6128739917	10/11/2017 12:40 PM
Contacts	Primary Contact	Insert			Pitzl, Michael Pharmacy Director 6128739917	5/3/2017 8:50 AM
Contacts	Authorizing Official	Insert			PRYOR, JON L. CEO 6128732343	11/7/2016 1:28 PM
Contacts	Signed By	Insert			PRYOR, JON L. CEO 6128732343	11/7/2016 1:28 PM
Addresses	Main Address	Insert			1425 10th Avenue South Minneapolis, MN 55404	8/19/2016 11:16 AM
Addresses	Shipping Address	Insert			Hennepin County Medical Center 730 So 8th St RL Pharmacy Minneapolis, MN 55415	8/19/2016 11:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/16/2016 4:16 PM
Medicaid Billing	Medicaid: Number	Insert			701906X	8/16/2016 4:16 PM
Medicaid Billing	Medicaid: State	Insert			MN	8/16/2016 4:16 PM
Medicaid Billing	NPI: Number	Insert			1265657746	8/16/2016 4:16 PM
Details	Last Recertification Date	Update		8/24/2015 12:00:00 AM	8/16/2016 12:00:00 AM	8/16/2016 4:16 PM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/24/2015 12:00:00 AM	8/24/2015 2:17 PM
Details	Last Recertification Date	Update			8/7/2014 12:00:00 AM	8/7/2014 2:00 PM
Dates	Participating Approval Date	Update			12/13/2013 12:00:00 AM	12/13/2013 7:07 AM
Details	State	Update		Pending	Active	12/13/2013 7:07 AM
Dates	Start Date	Update			1/1/2014 12:00:00 AM	12/13/2013 7:07 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH240004H	12/6/2013 6:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/7/2013 4:49 PM
Medicaid Billing	Medicaid: Number	Insert			157245800	10/7/2013 4:49 PM
Medicaid Billing	Medicaid: State	Insert			MN	10/7/2013 4:49 PM
Medicaid Billing	NPI: Number	Insert			1407897309	10/7/2013 4:49 PM
Details	Last Recertification Date	Insert				10/7/2013 4:49 PM
Details	Grant Number	Insert				10/7/2013 4:49 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	10/7/2013 4:49 PM
Details	Is Authorizing Official EHB Data	Insert				10/7/2013 4:49 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/7/2013 4:49 PM
Details	Medicare Provider Number	Insert			240004	10/7/2013 4:49 PM
Details	Entity Name	Insert			HENNEPIN COUNTY MEDICAL CENTER	10/7/2013 4:49 PM
Details	Program Code	Insert			DSH	10/7/2013 4:49 PM
Details	Entity Subname	Insert			HCMC Sr Care at Augustana	10/7/2013 4:49 PM
Dates	Participating Approval Date	Insert				10/7/2013 4:49 PM
Details	State	Insert			Pending	10/7/2013 4:49 PM
Dates	Registration Date	Insert			10/7/2013 12:00:00 AM	10/7/2013 4:49 PM
Dates	Signed By Date	Insert			10/7/2013 12:00:00 AM	10/7/2013 4:49 PM
Dates	Start Date	Insert				10/7/2013 4:49 PM
Terminations	Termination Comments	Insert				10/7/2013 4:49 PM
Terminations	Termination Date	Insert				10/7/2013 4:49 PM
Terminations	Termination Effective Date	Insert				10/7/2013 4:49 PM
Terminations	Termination Reason	Insert				10/7/2013 4:49 PM