Covered Entity Details

CAH241325-01 CCM Health (Terminated) - information as of 5/14/2025 10:55:16 PM

Main Details

Name

CCM Health

Subdivision Name

Montevideo Medical Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH241325-01

Medicare Provider Number

241325

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/10/2013

Participating Start Date

1/1/2014

Participating Approval Date

11/3/2013

Last Recertification Date

8/16/2023

Termination Date
Termination Reason

10/1/2024
Business decision by the Covered Entity

Contacts

Authorizing Official

CCM Health
Brian Lovdahl, CEO
(320) 321-8101

Primary Contact

CCM Health
Jamie L Malstrom, Director of Pharmacy
(320) 321-8175

Addresses

Street Address

824 North 11th Street
Montevideo, MN 56265

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		1720086028

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
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH241325-01	Child	CAH	CCM Health	Montevideo Medical Clinic	824 North 11th Street	Montevideo	MN	Terminated
CAH241325-02	Child	CAH	CCM Health	Clara City Clinic	140 NW 1st Ave.	Clara City	MN	Terminated
CAH241325-03	Child	CAH	CCM Health	CLARKFIELD CLINIC - Clarkfield Clinic	812 10TH AVE	CLARKFIELD	MN	Terminated
CAH241325-04	Child	CAH	CCM Health	MILAN CLINIC - Milan Clinic	237 2ND ST	MILAN	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		10/1/2024 12:00:00 AM	8/13/2024 8:52 AM
Details	State	Update	Termination Request	Active	To Be Terminated	8/13/2024 8:52 AM
Terminations	Termination Comments	Update	Termination Request		Clinic was always within the 4 walls of the covered entity. Does not need to be registered as a child site.	8/13/2024 8:52 AM
Terminations	Termination Date	Update	Termination Request		10/1/2024 12:00:00 AM	8/13/2024 8:52 AM
Terminations	Termination Effective Date	Update	Termination Request		10/1/2024 12:00:00 AM	8/13/2024 8:52 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	8/13/2024 8:52 AM
Details	Last Recertification Date	Update	Recertification	8/26/2022 8:18:02 AM	8/16/2023 9:09:28 AM	8/16/2023 9:09 AM
Contacts	Authorizing Official	Update	Profile Change Request	Lovdahl, Brian CEO CCM Health 3203218200-3203218101	Lovdahl, Brian CEO CCM Health 3203218101	5/10/2023 9:50 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 9:16:56 AM	8/26/2022 8:18:02 AM	8/26/2022 8:18 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1720086028	8/17/2021 9:33 AM
Medicaid Billing	NPI: State	Insert	Change Request		MN	8/17/2021 9:33 AM
Details	Last Recertification Date	Update	Recertification	9/3/2020 9:13:34 AM	8/16/2021 9:16:56 AM	8/16/2021 9:16 AM
Contacts	Primary Contact	Update	Change Request	Padula, Samantha Director of Pharmacy CCM Health 3203218175	Malstrom, Jamie L Director of Pharmacy CCM Health 3203218175	3/18/2021 9:02 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 7:59:25 AM	9/3/2020 9:13:34 AM	9/3/2020 9:13 AM
Contacts	Primary Contact	Update	Profile Change Request	Padula, Samantha Director of Pharmacy CCM Health 3203218168-3203218175	Padula, Samantha Director of Pharmacy CCM Health 3203218175	8/27/2020 5:10 PM
Contacts	Authorizing Official	Update	Change Request	Lovdahl, Brian CEO CCM Health 3203218200	Lovdahl, Brian CEO CCM Health 3203218200-3203218101	4/8/2020 3:50 PM
Contacts	Primary Contact	Update	Change Request	Padula, Samantha Director of Pharmacy CCM Health 3203218168	Padula, Samantha Director of Pharmacy CCM Health 3203218168-3203218175	4/8/2020 3:09 PM
Details	Last Recertification Date	Update	Recertification	8/29/2018 4:13:28 PM	8/20/2019 7:59:25 AM	8/20/2019 7:59 AM
Contacts	Primary Contact	Update	Change Request	Padula, Samantha May Director of Pharmacy CCM Health 3203218168	Padula, Samantha Director of Pharmacy CCM Health 3203218168	8/15/2019 6:58 AM
Contacts	Authorizing Official	Update	Change Request	Lovdahl, Brian CEO CCM Health 3203218200	Lovdahl, Brian CEO CCM Health 3203218200	8/12/2019 7:05 AM
Details	Entity Name	Update	Change Request	Chippewa County Montevideo Hospital	CCM Health	8/12/2019 7:05 AM
Contacts	Authorizing Official	Update	Profile Change Request	Lovdahl, Brian CEO CCMH 3203218100	Lovdahl, Brian CEO CCM Health 3203218200	8/8/2019 2:41 PM
Contacts	Primary Contact	Update	Profile Change Request	Padula, Samantha May Director of Pharmacy Chippewa County Montevideo Hospital 3203218168	Padula, Samantha May Director of Pharmacy CCM Health 3203218168	8/7/2019 4:20 PM
Details	Last Recertification Date	Update	Recertification	11/6/2017 2:49:48 PM	8/29/2018 4:13:28 PM	8/29/2018 4:13 PM
Contacts	Authorizing Official	Update	Change Request	Lindgren, Jeremiah COO Chippewa County Montevideo Hospital 3203218274	Lovdahl, Brian CEO CCMH 3203218100	8/14/2018 7:37 AM
Contacts	Primary Contact	Update	Recertification	Paulson, Mark E. Administrator 3203218100	Padula, Samantha May Director of Pharmacy Chippewa County Montevideo Hospital 3203218168	11/6/2017 2:49 PM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	11/6/2017 2:49:48 PM	11/6/2017 2:49 PM
Contacts	Authorizing Official	Update	AO Change Request	Paulson, Mark E. Administrator 3203218100	Lindgren, Jeremiah COO Chippewa County Montevideo Hospital 3203218274	10/23/2017 2:25 PM
Addresses	Main Address	Insert			824 North 11th Street Montevideo, MN 56265	8/12/2016 12:10 PM
Contacts	Authorizing Official	Insert			Paulson, Mark E. Administrator 3203218100	8/12/2016 12:10 PM
Contacts	Primary Contact	Insert			Paulson, Mark E. Administrator 3203218100	8/12/2016 12:10 PM
Contacts	Signed By	Insert			Paulson, Mark E. Administrator 3203218100	8/12/2016 12:10 PM
Details	Last Recertification Date	Update		8/21/2015 12:00:00 AM	8/12/2016 12:00:00 AM	8/12/2016 12:10 PM
Details	Last Recertification Date	Update		8/6/2014 12:00:00 AM	8/21/2015 12:00:00 AM	8/21/2015 10:51 AM
Details	Last Recertification Date	Update			8/6/2014 12:00:00 AM	8/6/2014 9:57 AM
Dates	Participating Approval Date	Update			11/3/2013 12:00:00 AM	11/3/2013 7:05 PM
Details	State	Update		Pending	Active	11/3/2013 7:05 PM
Dates	Start Date	Update			1/1/2014 12:00:00 AM	11/3/2013 7:05 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	CAH241325-01	10/29/2013 2:44 PM
Details	Last Recertification Date	Insert				10/10/2013 12:27 PM
Details	Grant Number	Insert				10/10/2013 12:27 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	10/10/2013 12:27 PM
Details	Is Authorizing Official EHB Data	Insert				10/10/2013 12:27 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/10/2013 12:27 PM
Details	Medicare Provider Number	Insert			241325	10/10/2013 12:27 PM
Details	Entity Name	Insert			Chippewa County Montevideo Hospital	10/10/2013 12:27 PM
Details	Program Code	Insert			CAH	10/10/2013 12:27 PM
Details	Entity Subname	Insert			Montevideo Medical Clinic	10/10/2013 12:27 PM
Dates	Participating Approval Date	Insert				10/10/2013 12:27 PM
Details	State	Insert			Pending	10/10/2013 12:27 PM
Dates	Registration Date	Insert			10/10/2013 12:00:00 AM	10/10/2013 12:27 PM
Dates	Signed By Date	Insert			10/10/2013 12:00:00 AM	10/10/2013 12:27 PM
Dates	Start Date	Insert				10/10/2013 12:27 PM
Terminations	Termination Comments	Insert				10/10/2013 12:27 PM
Terminations	Termination Date	Insert				10/10/2013 12:27 PM
Terminations	Termination Effective Date	Insert				10/10/2013 12:27 PM
Terminations	Termination Reason	Insert				10/10/2013 12:27 PM