Covered Entity Details

CAH241367-03 Welia Health (Active) - information as of 4/29/2025 11:47:02 PM

Main Details

Name

Welia Health

Subdivision Name

Welia Health - Hinckley Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH241367-03

Medicare Provider Number

241367

Outpatient Facility Provider Number

243463

Additional Details

Current Program Status

Active

Registration Date

1/3/2014

Participating Start Date

4/1/2014

Participating Approval Date

1/9/2014

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Welia Health
Randy William Ulseth, CEO
(320) 225-3315

Primary Contact

Welia Health
Joe Dvorak, Director of Pharmacy
(320) 225-3592

Addresses

Street Address

620 Sandy Lane
Hinckley, MN 55037

Billing Address

Welia Health
301 Highway 65 S
Mora, MN 55051

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	1528031390,1972811362,1992012207,1073821468	1528031390,1972811362,1992012207,1073821468

Shipping Addresses

Shipping Address 1

Welia Health
301 Highway 65 S
Mora, MN 55051

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
CAH241367-01	Child	CAH	Welia Health	Welia Health - Mora Clinic	301 Highway 65 S	Mora	MN	Active
CAH241367-02	Child	CAH	Welia Health	Welia Health - Pine City Clinic	1425 Main St. North	Pine City	MN	Active
CAH241367-03	Child	CAH	Welia Health	Welia Health - Hinckley Clinic	620 Sandy Lane	Hinckley	MN	Active
CAH241367-04	Child	CAH	Welia Health	Welia Health - Urgency Services	1425 MAIN ST N	PINE CITY	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/21/2023 2:21:23 PM	8/19/2024 9:10:41 AM	8/19/2024 9:10 AM
Contacts	Primary Contact	Update	Profile Change Request	Dvorak, Joe Community Pharmacy Director Welia Health 3203225141	Dvorak, Joe Director of Pharmacy Welia Health 3202253592	10/27/2023 5:07 PM
Addresses	Billing Address	Insert	Change Request		Welia Health 301 Highway 65 S Mora, MN 55051	10/19/2023 1:48 PM
Addresses	Shipping Address	Insert	Change Request		Welia Health 301 Highway 65 S Mora, MN 55051	10/19/2023 1:48 PM
Contacts	Primary Contact	Update	Change Request	Thompson, Brent Jason DOP Welia Health 3202253595	Dvorak, Joe Community Pharmacy Director Welia Health 3203225141	9/27/2023 9:27 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 1:27:00 PM	8/21/2023 2:21:23 PM	8/21/2023 2:21 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1841761871 (MN)		3/21/2023 9:45 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1407276264 (MN)		3/21/2023 9:45 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1841761871 (MN)		3/21/2023 9:45 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1407276264 (MN)		3/21/2023 9:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528031390	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1972811362	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1992012207	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1073821468	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841761871	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1407276264	12/13/2022 4:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1528031390	12/13/2022 4:00 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1972811362	12/13/2022 4:00 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1992012207	12/13/2022 4:00 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073821468	12/13/2022 4:00 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841761871	12/13/2022 4:00 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1407276264	12/13/2022 4:00 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	12/13/2022 4:00 PM
Details	Last Recertification Date	Update	Recertification	8/23/2021 11:19:40 AM	8/24/2022 1:27:00 PM	8/24/2022 1:27 PM
Details	Last Recertification Date	Update	Recertification	8/27/2020 9:28:47 AM	8/23/2021 11:19:40 AM	8/23/2021 11:19 AM
Details	Last Recertification Date	Update	Recertification	8/19/2019 4:55:49 PM	8/27/2020 9:28:47 AM	8/27/2020 9:28 AM
Contacts	Signed By	Update	Profile Change Request	Ulseth, Randy CEO FirstLight Health System 3202253315	Ulseth, Randy CEO Welia Health 3202253315	8/20/2020 11:17 AM
Contacts	Primary Contact	Update	Change Request	Thompson, Brent Jason DOP FirstLight Health System 3202253595	Thompson, Brent Jason DOP Welia Health 3202253595	10/15/2019 9:11 AM
Contacts	Authorizing Official	Update	Change Request	Ulseth, Randy CEO FirstLight Health System 3202253315	Ulseth, Randy William CEO Welia Health 3202253315	10/11/2019 10:08 AM
Details	Entity Subname	Update	Change Request	FirstLight Health System - Hinckley Clinic	Welia Health - Hinckley Clinic	9/23/2019 3:19 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 4:04:55 PM	8/19/2019 4:55:49 PM	8/19/2019 4:55 PM
Details	Last Recertification Date	Update	Recertification	11/21/2017 5:35:30 PM	8/24/2018 4:04:55 PM	8/24/2018 4:04 PM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/21/2017 5:35:30 PM	11/21/2017 5:35 PM
Contacts	Authorizing Official	Update		Ulseth, Randy CEO 3202253315	Ulseth, Randy CEO FirstLight Health System 3202253315	10/4/2017 3:13 PM
Contacts	Signed By	Update		Ulseth, Randy CEO 3202253315	Ulseth, Randy CEO FirstLight Health System 3202253315	10/4/2017 3:13 PM
Contacts	Primary Contact	Update		Thompson, Brent DOP 3202253595	Thompson, Brent Jason DOP FirstLight Health System 3202253595	10/4/2017 2:44 PM
Contacts	Authorizing Official	Insert			Ulseth, Randy CEO 3202253315	1/16/2017 9:25 AM
Contacts	Signed By	Insert			Ulseth, Randy CEO 3202253315	1/16/2017 9:25 AM
Addresses	Main Address	Insert			620 Sandy Lane Hinckley, MN 55037	8/17/2016 10:08 AM
Contacts	Primary Contact	Insert			Thompson, Brent DOP 3202253595	8/17/2016 10:08 AM
Details	Last Recertification Date	Update		8/19/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 10:08 AM
Details	Last Recertification Date	Update		8/12/2014 12:00:00 AM	8/19/2015 12:00:00 AM	8/19/2015 10:28 AM
Details	Last Recertification Date	Update			8/12/2014 12:00:00 AM	8/12/2014 11:01 AM
Dates	Participating Approval Date	Update			1/9/2014 12:00:00 AM	1/9/2014 2:49 PM
Details	State	Update		Pending	Active	1/9/2014 2:49 PM
Dates	Start Date	Update			4/1/2014 12:00:00 AM	1/9/2014 2:49 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	CAH241367-03	1/7/2014 1:46 PM
Details	Last Recertification Date	Insert				1/3/2014 12:29 PM
Details	Grant Number	Insert				1/3/2014 12:29 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	1/3/2014 12:29 PM
Details	Is Authorizing Official EHB Data	Insert				1/3/2014 12:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/3/2014 12:29 PM
Details	Medicare Provider Number	Insert			241367	1/3/2014 12:29 PM
Details	Entity Name	Insert			FirstLight Health System	1/3/2014 12:29 PM
Details	Program Code	Insert			CAH	1/3/2014 12:29 PM
Details	Entity Subname	Insert			FirstLight Health System - Hinckley Clinic	1/3/2014 12:29 PM
Dates	Participating Approval Date	Insert				1/3/2014 12:29 PM
Details	State	Insert			Pending	1/3/2014 12:29 PM
Dates	Registration Date	Insert			1/3/2014 12:00:00 AM	1/3/2014 12:29 PM
Dates	Signed By Date	Insert			1/3/2014 12:00:00 AM	1/3/2014 12:29 PM
Dates	Start Date	Insert				1/3/2014 12:29 PM
Terminations	Termination Comments	Insert				1/3/2014 12:29 PM
Terminations	Termination Date	Insert				1/3/2014 12:29 PM
Terminations	Termination Effective Date	Insert				1/3/2014 12:29 PM
Terminations	Termination Reason	Insert				1/3/2014 12:29 PM