340B Drug Pricing Program Database


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

Main Details
HENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER
HCMC Sr Care at Augustana
Disproportionate Share Hospital
No
DSH240004H
240004


Additional Details
Terminated
10/7/2013
1/1/2014
12/13/2013
9/5/2019

10/1/2020
Site closure

Contacts

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

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

Addresses

1425 10th Avenue South
Minneapolis, MN 55404

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
CommentLast Updated On 
No records to display.
Medicaid Billing

Yes
StateMedicaid NumberNPI Number
MN157245800,701906X 
  1407897309
Shipping Addresses

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

Hennepin Healthcare System, Inc. - Hennepin County Medical Center
901 South 6th Street
Minneapolis, MN 55415
Parent/Child
340B IDHierarchyEntity TypeNameSub NameAddressCityState340B Status
DSH240004AChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERWHITTIER CLINIC2810 NICOLLET AVE.MINNEAPOLISMNActive
DSH240004AAChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Eye Clinic715 South 8th Street 4th Floor 410MinneapolisMNActive
DSH240004ABChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Pediatric Clinic715 South 8th Street 3rd Floor 309 & 310MinneapolisMNActive
DSH240004ACChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCoordinated Care Center900 South 8th Street Suite S1.300MinneapolisMNActive
DSH240004ADChildDSHHENNEPIN COUNTY MEDICAL CENTERMedicine Clinic716 South 7th Street Suite P7MinneapolisMNTerminated
DSH240004AEChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Women's Health and Wellness Clinic and OB/GYN Clinic715 South 8th Street 5th Floor 504 & 505MinneapolisMNActive
DSH240004AFChildDSHHENNEPIN COUNTY MEDICAL CENTERAddiction Medicine Clinic701 PARK AVEMINNEAPOLISMNTerminated
DSH240004AGChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERSleep Center Clinic900 South 8th Street Suite G8.220MinneapolisMNActive
DSH240004AHChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Gastroenterology & Liver Clinic715 South 8th Street 5th Floor 508MinneapolisMNActive
DSH240004AJChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Diabetes & Endocrinology Care Clinic715 South 8th Street 2nd Floor 204MinneapolisMNActive
DSH240004AKChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Rheumatology Clinic715 South 8th Street 2nd Floor 203MinneapolisMNActive
DSH240004ALChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Pulmonary Clinic / Pulmonary Function Lab715 South 8th Street 2nd Floor 201 & 202MinneapolisMNActive
DSH240004AMChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Dermatology Clinic715 South 8th Street 3rd Floor 308MinneapolisMNActive
DSH240004ANChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERBE WELL CLINIC - HCMC Be Well Clinic701 4TH AVE. S, STE. 100MINNEAPOLISMNTerminated
DSH240004APChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERGOLDEN VALLEY CLINIC - HCMC - HCMC Golden Valley Clinic5653 DULUTH STREETGOLDEN VALLEYMNActive
DSH240004AQChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERRICHFIELD CLINIC - Richfield Clinic790 W 66TH STRICHFIELDMNActive
DSH240004ARChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERST. ANTHONY VILLAGE CLINIC - St. Anthony Village Clinic2714 Highway 88St. AnthonyMNActive
DSH240004ASChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERNorth Loop Clinic - North Loop Clinic800 Washington Ave. NorthMinneapolisMNActive
DSH240004ATChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Echo Cardiography - Echo Cardiography715 South 8th Street, Level 2MinneapolisMNActive
DSH240004AUChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC EKG Diagnostic Lab - EKG Diagnostic Lab715 South 8th Street, Level 2MinneapolisMNActive
DSH240004AVChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC EMG Diagnostic Lab - EMG Diagnostic Lab715 South 8th Street, Level 3MinneapolisMNActive
DSH240004AWChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Integrative Health Clinic - Integrative Health Clinic715 South 8th Street, Level 3MinneapolisMNActive
DSH240004AXChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Mammography - Mammography715 South 8th Street, Level 1MinneapolisMNActive
DSH240004AYChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Medicine Clinic - Medicine Clinic715 South 8 Street, Level 2MinneapolisMNActive
DSH240004AZChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Occupational Therapy - Occupational Therapy715 South 8th Street, Level 3MinneapolisMNActive
DSH240004BChildDSHHENNEPIN COUNTY MEDICAL CENTERBrooklyn Center Clinic6601 Shingle Creek ParkwayBrooklyn CenterMNTerminated
DSH240004BAChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Orthopedic Clinic - Orthopedic Clinic715 South 8th Street, Level 1MinneapolisMNActive
DSH240004BBChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Outpatient Cardiac Rehab - Outpatient Cardiac Rehab715 South 8th Street, Level 2MinneapolisMNActive
DSH240004BCChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Physical Therapy - Physical Therapy715 South 8th Street, Level 3MinneapolisMNActive
DSH240004BDChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC PMR and TBI Clinic - PMR and TBI Clinic715 South 8th Street, Level 3MinneapolisMNActive
DSH240004BEChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Radiation Therapy - Radiation Therapy715 South 8th Street, Lower LevelMinneapolisMNActive
DSH240004BFChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Speech-Language Pathology - Speech-Language Pathology715 South 8th Street, Level 3MinneapolisMNActive
DSH240004BGChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Surgery Clinic - Surgery Clinic715 South 8th Street, Level 5MinneapolisMNActive
DSH240004BHChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Ultrasound - Ultrasound715 South 8th Street, Level 1MinneapolisMNActive
DSH240004BJChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERSenior Care Clinic Parkside - Senior Care Clinic825 South 8th Street, Suite 440MinneapolisMNTerminated
DSH240004BKChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Operating Room - CSC Operating Room715 South 8th StreetMinneapolisMNActive
DSH240004BLChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERHennepin Healthcare Hospice - Hospice2000 Summer St. NEMinneapolisMNTerminated
DSH240004BMChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Radiation Therapy - Radiation Oncology715 South 8th Street Level 1MinneapolisMNActive
DSH240004BNChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Computed Tomography - Computed Tomography Scan715 South 8th Street Level 1MinneapolisMNActive
DSH240004BPChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC OB Testing Diagnostic Lab - OB Testing Diagnostic Lab715 South 8th Street Level 5MinneapolisMNActive
DSH240004BQChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERHCMC Whittier Clinic Speech Language Pathology - Speech Pathology2810 Nicollet Ave. SMinneapolisMNActive
DSH240004BRChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERHENNEPIN HEALTHCARE SYSTEM INC - Comprehensive Weight Mgmt Ctr701 PARK AVEMINNEAPOLISMNActive
DSH240004BSChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERHennepin Healthcare System - Neurosurgery Clinic - CSC Level 3715 South 8th St - Level 3MinneapolisMNActive
DSH240004BTChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Same Day Access Clinic715 South 8th Street 203, 208, 209MinneapolisMNActive
DSH240004CChildDSHHENNEPIN COUNTY MEDICAL CENTERRichfield Clinic44 West 66th StreetRichfieldMNTerminated
DSH240004DChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTEREast Lake Clinic2215 East Lake StreetMinneapolisMNActive
DSH240004EChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERBrooklyn Park Clinic7650 Zane Avenue NorthBrooklyn ParkMNActive
DSH240004FChildDSHHENNEPIN COUNTY MEDICAL CENTERNeurology and Specialty Clinic111 Hundertmark RoadChaskaMNTerminated
DSH240004HChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERHCMC Sr Care at Augustana1425 10th Avenue SouthMinneapolisMNTerminated
DSH240004JChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Dental & Oral Surgery Clinic715 South 8th Street 4th Floor 408MinneapolisMNActive
DSH240004KChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERTransplant Clinic900 South 8th Street Suite B1.310MinneapolisMNActive
DSH240004LChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Infusion Center715 South 8th Street 1st Floor A1.820MinneapolisMNActive
DSH240004MChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Urology Clinic715 South 8th Street 5th Floor 507MinneapolisMNActive
DSH240004NChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Interventional Pain Clinic715 South 8th Street 5th Floor 510MinneapolisMNActive
DSH240004PChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Internal Medicine Clinic715 South 8th Street 203, 208 & 209MinneapolisMNActive
DSH240004QChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Allergy Clinic715 South 8th Street 1st Floor 108MinneapolisMNActive
DSH240004RChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERAddiction Medicine Clinic914 S. 8th StreetMinneapolisMNActive
DSH240004SChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERPositive Care Clinic913 South 7th Street Suite B1.290MinneapolisMNActive
DSH240004TChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Cardiology Clinic715 South 8th Street 2nd Floor 201 & 202MinneapolisMNActive
DSH240004UChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Cancer Center715 South 8th Street 1st Floor A1.744MinneapolisMNActive
DSH240004VChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC Neurology Clinic715 South 8th Street 3rd Floor 301MinneapolisMNActive
DSH240004WChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERChronic Wound Care716 South 7th Street P1.600MinneapolisMNActive
DSH240004XChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERBurn Clinic716 South 7th Street Suite P4MinneapolisMNActive
DSH240004YChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERCSC ENT Clinic715 South 8th Street 3rd Floor 301MinneapolisMNActive
DSH240004ZChildDSHHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTERAdult Psychiatry Clinic914 South 8th Street Suite 110MinneapolisMNActive
History
SectionFieldActionActivityValue BeforeValue AfterTimestamp 
DetailsStateUpdate To Be TerminatedTerminated10/1/2020 12:01 AM
DatesLast Date That 340B Drugs PurchasedUpdateTermination Request 2/28/2020 12:00:00 AM7/14/2020 8:34 AM
DetailsStateUpdateTermination RequestActiveTo Be Terminated7/14/2020 8:34 AM
TerminationsTermination DateUpdateTermination Request 10/1/2020 12:00:00 AM7/14/2020 8:34 AM
TerminationsTermination Effective DateUpdateTermination Request 2/28/2020 12:00:00 AM7/14/2020 8:34 AM
TerminationsTermination ReasonUpdateTermination Request Site closure7/14/2020 8:34 AM
ContactsAuthorizing OfficialUpdateAO Change RequestCumming, John Interim CEO Hennepin Healthcare Systems, Inc. - HCMC 6128733000Blomberg, Emily Chief Operating Official Hennepin County Medical Center - Hennepin Healthcare Inc 61287399133/1/2020 8:13 PM
DetailsLast Recertification DateUpdateRecertification8/15/2018 10:33:32 AM9/5/2019 12:13:58 PM9/5/2019 12:13 PM
ContactsAuthorizing OfficialUpdateChange RequestPRYOR, JON L. CEO Hennepin Healthcare System, INC - HCMC 6128733000Cumming, John Interim CEO Hennepin Healthcare Systems, Inc. - HCMC 61287330002/8/2019 9:49 AM
ContactsAuthorizing OfficialUpdateProfile Change RequestPRYOR, JON L. CEO Hennepin Healthcare System, INC - Hennepin County Medical Center 6128733000PRYOR, JON L. CEO Hennepin Healthcare System, INC - HCMC 61287330008/15/2018 10:44 AM
ContactsSigned ByUpdateProfile Change RequestPRYOR, JON L. CEO Hennepin Healthcare System, INC - Hennepin County Medical Center 6128733000PRYOR, JON L. CEO Hennepin Healthcare System, INC - HCMC 61287330008/15/2018 10:44 AM
ContactsAuthorizing OfficialUpdateProfile Change RequestPRYOR, JON L. CEO Hennepin County Medical Center 6128733000PRYOR, JON L. CEO Hennepin Healthcare System, INC - Hennepin County Medical Center 61287330008/15/2018 10:43 AM
ContactsSigned ByUpdateProfile Change RequestPRYOR, JON L. CEO Hennepin County Medical Center 6128733000PRYOR, JON L. CEO Hennepin Healthcare System, INC - Hennepin County Medical Center 61287330008/15/2018 10:43 AM
DetailsLast Recertification DateUpdateRecertification11/8/2017 12:46:36 PM8/15/2018 10:33:32 AM8/15/2018 10:33 AM
ContactsAuthorizing OfficialUpdateProfile Change RequestPRYOR, JON L. CEO Hennepin County Medical Center 6128732343PRYOR, JON L. CEO Hennepin County Medical Center 61287330008/15/2018 10:11 AM
ContactsSigned ByUpdateProfile Change RequestPRYOR, JON L. CEO Hennepin County Medical Center 6128732343PRYOR, JON L. CEO Hennepin County Medical Center 61287330008/15/2018 10:11 AM
DetailsEntity NameUpdateChange RequestHENNEPIN COUNTY MEDICAL CENTERHENNEPIN HEALTHCARE SYSTEM, INC. - HENNEPIN COUNTY MEDICAL CENTER7/27/2018 12:11 PM
AddressesShipping AddressDeleteChange RequestHennepin County Medical Center 901 South 6th Street Minneapolis, MN 55415 7/27/2018 11:41 AM
AddressesBilling AddressInsertChange Request Hennepin Healthcare System, Inc. - Hennepin County Medical Center 701 Park Ave. South Minneapolis, MN 554157/27/2018 11:41 AM
AddressesShipping AddressInsertChange Request Hennepin Healthcare System, Inc. - Hennepin County Medical Center 730 So 8th St RL Pharmacy Minneapolis, MN 554157/27/2018 11:41 AM
AddressesShipping AddressInsertChange Request Hennepin Healthcare System, Inc. - Hennepin County Medical Center 901 South 6th Street Minneapolis, MN 554157/27/2018 11:41 AM
AddressesShipping AddressDeleteChange RequestHennepin County Medical Center 730 So 8th St RL Pharmacy Minneapolis, MN 55415 7/27/2018 11:41 AM
Medicaid BillingNPI: NumberDeleteChange Request1265657746 ( ) 7/27/2018 11:41 AM
ContactsPrimary ContactUpdateChange RequestPitzl, Michael Pharmacy Director Hennepin County Medical Center 6128739917Jolowsky, Christene Marie Pharmacy Director Hennepin Healthcare Systems, Inc. - HCMC 61287399177/27/2018 11:41 AM
AddressesShipping AddressInsertRecertification Hennepin County Medical Center 901 South 6th Street Minneapolis, MN 5541511/8/2017 12:46 PM
DetailsLast Recertification DateUpdateRecertification10/25/2017 11:47:52 AM11/8/2017 12:46:36 PM11/8/2017 12:46 PM
DetailsLast Recertification DateUpdateRecertification8/16/2016 12:00:00 AM10/25/2017 11:47:52 AM10/25/2017 11:47 AM
ContactsAuthorizing OfficialUpdateNew RegistrationPRYOR, JON L. CEO 6128732343PRYOR, JON L. CEO Hennepin County Medical Center 612873234310/12/2017 12:46 PM
ContactsSigned ByUpdateNew RegistrationPRYOR, JON L. CEO 6128732343PRYOR, JON L. CEO Hennepin County Medical Center 612873234310/12/2017 12:46 PM
ContactsPrimary ContactUpdate Pitzl, Michael Pharmacy Director 6128739917Pitzl, Michael Pharmacy Director Hennepin County Medical Center 612873991710/11/2017 12:40 PM
ContactsPrimary ContactInsert  Pitzl, Michael Pharmacy Director 61287399175/3/2017 8:50 AM
ContactsAuthorizing OfficialInsert  PRYOR, JON L. CEO 612873234311/7/2016 1:28 PM
ContactsSigned ByInsert  PRYOR, JON L. CEO 612873234311/7/2016 1:28 PM
AddressesMain AddressInsert   1425 10th Avenue South Minneapolis, MN 554048/19/2016 11:16 AM
AddressesShipping AddressInsert  Hennepin County Medical Center 730 So 8th St RL Pharmacy Minneapolis, MN 554158/19/2016 11:16 AM
Medicaid BillingMedicaid: Is PrimaryInsert  False8/16/2016 4:16 PM
Medicaid BillingMedicaid: NumberInsert  701906X8/16/2016 4:16 PM
Medicaid BillingMedicaid: StateInsert  MN8/16/2016 4:16 PM
Medicaid BillingNPI: NumberInsert  12656577468/16/2016 4:16 PM
DetailsLast Recertification DateUpdate 8/24/2015 12:00:00 AM8/16/2016 12:00:00 AM8/16/2016 4:16 PM
DetailsLast Recertification DateUpdate 8/7/2014 12:00:00 AM8/24/2015 12:00:00 AM8/24/2015 2:17 PM
DetailsLast Recertification DateUpdate  8/7/2014 12:00:00 AM8/7/2014 2:00 PM
DatesParticipating Approval DateUpdate  12/13/2013 12:00:00 AM12/13/2013 7:07 AM
DetailsStateUpdate PendingActive12/13/2013 7:07 AM
DatesStart DateUpdate  1/1/2014 12:00:00 AM12/13/2013 7:07 AM
Details340B IDUpdate OUTPATIENT_ONLINE_REGDSH240004H12/6/2013 6:34 PM
Medicaid BillingMedicaid: Is PrimaryInsert  False10/7/2013 4:49 PM
Medicaid BillingMedicaid: NumberInsert  15724580010/7/2013 4:49 PM
Medicaid BillingMedicaid: StateInsert  MN10/7/2013 4:49 PM
Medicaid BillingNPI: NumberInsert  140789730910/7/2013 4:49 PM
DetailsLast Recertification DateInsert   10/7/2013 4:49 PM
DetailsGrant NumberInsert   10/7/2013 4:49 PM
Details340B IDInsert  OUTPATIENT_ONLINE_REG10/7/2013 4:49 PM
DetailsIs Authorizing Official EHB DataInsert   10/7/2013 4:49 PM
DatesLast Date That 340B Drugs PurchasedInsert   10/7/2013 4:49 PM
DetailsMedicare Provider NumberInsert  24000410/7/2013 4:49 PM
DetailsEntity NameInsert  HENNEPIN COUNTY MEDICAL CENTER10/7/2013 4:49 PM
DetailsProgram CodeInsert  DSH10/7/2013 4:49 PM
DetailsEntity SubnameInsert  HCMC Sr Care at Augustana10/7/2013 4:49 PM
DatesParticipating Approval DateInsert   10/7/2013 4:49 PM
DetailsStateInsert  Pending10/7/2013 4:49 PM
DatesRegistration DateInsert  10/7/2013 12:00:00 AM10/7/2013 4:49 PM
DatesSigned By DateInsert  10/7/2013 12:00:00 AM10/7/2013 4:49 PM
DatesStart DateInsert   10/7/2013 4:49 PM
TerminationsTermination CommentsInsert   10/7/2013 4:49 PM
TerminationsTermination DateInsert   10/7/2013 4:49 PM
TerminationsTermination Effective DateInsert   10/7/2013 4:49 PM
TerminationsTermination ReasonInsert   10/7/2013 4:49 PM