| Details | State | Update | | To Be Terminated | Terminated | 10/1/2024 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Hospital Type Change Request | | 10/1/2024 12:00:00 AM | 7/31/2024 12:36 PM |
| Details | State | Update | Hospital Type Change Request | Active | To Be Terminated | 7/31/2024 12:36 PM |
| Terminations | Termination Date | Update | Hospital Type Change Request | | 10/1/2024 12:00:00 AM | 7/31/2024 12:36 PM |
| Terminations | Termination Effective Date | Update | Hospital Type Change Request | | 10/1/2024 12:00:00 AM | 7/31/2024 12:36 PM |
| Terminations | Termination Reason | Update | Hospital Type Change Request | | Change of covered entity type | 7/31/2024 12:36 PM |
| Contacts | Primary Contact | Update | Group Change Request | Brooks-Dockendorf, Rhonda
340B Program Coordinator
Essentia Health
2187864423 | Sharrow, Nick
Pharmacy Business Services Director
Essentia Health
2186069246 | 2/27/2024 1:02 PM |
| Contacts | Primary Contact | Update | Group Change Request | Sedlachek, Andrea
340B Senior Coordinator
Essentia Health
2183936699 | Brooks-Dockendorf, Rhonda
340B Program Coordinator
Essentia Health
2187864423 | 11/7/2023 9:06 AM |
| Details | Last Recertification Date | Update | Recertification | 9/4/2022 1:34:46 PM | 8/15/2023 7:51:34 AM | 8/15/2023 7:51 AM |
| Contacts | Primary Contact | Update | PC Change Request | Olivier, Ryan
Pharmacy 340B Manager
Essentia Health
2185760677 | Sedlachek, Andrea
340B Senior Coordinator
Essentia Health
2183936699 | 5/25/2023 9:31 AM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2021 3:49:49 PM | 9/4/2022 1:34:46 PM | 9/4/2022 1:34 PM |
| Contacts | Primary Contact | Update | Group Change Request | Kaufenberg, Anthony
Vice President, Pharmacy
Essentia Health
2188287693 | Olivier, Ryan
Pharmacy 340B Manager
Essentia Health
2185760677 | 9/13/2021 7:43 AM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2020 9:32:53 AM | 9/9/2021 3:49:49 PM | 9/9/2021 3:49 PM |
| Contacts | Primary Contact | Update | Group Change Request | Heide, Dawn
340B Senior Program Coordinator
Essentia Health
2188287143 | Kaufenberg, Anthony
Vice President, Pharmacy
Essentia Health
2188287693 | 7/8/2021 4:04 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1457393035 (ND) | | 4/8/2021 4:31 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1457393035 (SD) | | 4/8/2021 4:31 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1457393035 (IA) | | 4/8/2021 4:31 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1457393035 (IL) | | 4/8/2021 4:31 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1457393035 (NY) | | 4/8/2021 4:31 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1457393035 (CA) | | 4/8/2021 4:31 PM |
| Contacts | Primary Contact | Update | Change Request | Lundberg, Bryan
340b Program Manager
Essentia Health
2188287143 | Heide, Dawn
340B Senior Program Coordinator
Essentia Health
2188287143 | 1/25/2021 10:40 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Lundberg, Bryan
340b Program Manager
Essentia Health
2185760745 | Lundberg, Bryan
340b Program Manager
Essentia Health
2188287143 | 10/9/2020 9:19 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1457393035 | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | WI | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1457393035 | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MI | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1457393035 | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | ND | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1457393035 | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | SD | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1457393035 | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | IA | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1457393035 | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | IL | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1457393035 | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | NY | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1457393035 | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 8/25/2020 9:32 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | MN | 8/25/2020 9:32 AM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2019 10:02:27 AM | 8/25/2020 9:32:53 AM | 8/25/2020 9:32 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Lundberg, Bryan
340b Program Manager
Essentia
2185760745 | Lundberg, Bryan
340b Program Manager
Essentia Health
2185760745 | 4/1/2020 10:07 AM |
| Addresses | Main Address | Update | Change Request |
420 East First Street
Duluth, MN 55805 |
420 E 1ST ST
DULUTH, MN 55805 | 1/28/2020 4:08 PM |
| Details | Entity Subname | Update | Change Request | ESSENTIA HEALTH ST MARYS MEDICAL CE / Endoscopy | Essentia Health St. Marys Medical Center / Endoscopy | 1/28/2020 4:08 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2018 3:10:44 PM | 8/29/2019 10:02:27 AM | 8/29/2019 10:02 AM |
| Contacts | Authorizing Official | Update | Change Request | Garvey, James M.
SVP Hospital Operations East Region
Essentia Health
2187864878 | Beard, Bradley
Chief Operating Officer
Essentia Health
2187862652 | 8/1/2019 12:11 AM |
| Details | Last Recertification Date | Update | Recertification | 11/29/2017 10:46:01 AM | 9/7/2018 3:10:44 PM | 9/7/2018 3:10 PM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2016 12:00:00 AM | 11/29/2017 10:46:01 AM | 11/29/2017 10:46 AM |
| Contacts | Authorizing Official | Update | | Garvey, James M.
SVP Hospital Operations East Region
2187864878 | Garvey, James M.
SVP Hospital Operations East Region
Essentia Health
2187864878 | 10/3/2017 10:42 AM |
| Contacts | Primary Contact | Update | | Lundberg, Bryan
340b Program Manager
2185760745 | Lundberg, Bryan
340b Program Manager
Essentia
2185760745 | 9/20/2017 3:06 PM |
| Contacts | Primary Contact | Insert | | | Lundberg, Bryan
340b Program Manager
2185760745 | 8/14/2017 1:06 PM |
| Contacts | Authorizing Official | Insert | | | Garvey, James M.
SVP Hospital Operations East Region
2187864878 | 8/11/2017 9:47 AM |
| Addresses | Main Address | Insert | | |
420 East First Street
Duluth, MN 55805 | 12/15/2016 8:49 AM |
| Contacts | Signed By | Insert | | | Garvey, James M.
EVP
2187864878 | 12/15/2016 8:49 AM |
| Details | Last Recertification Date | Update | | 9/3/2015 12:00:00 AM | 8/30/2016 12:00:00 AM | 8/30/2016 2:30 PM |
| Details | Last Recertification Date | Update | | | 9/3/2015 12:00:00 AM | 9/3/2015 9:45 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1457393035 | 4/17/2015 3:40 PM |
| Details | Entity Subname | Update | | ESSENTIA HEALTH ST MARYS MEDICAL CE | ESSENTIA HEALTH ST MARYS MEDICAL CE / Endoscopy | 12/19/2014 2:16 PM |
| Dates | Participating Approval Date | Update | | | 9/5/2014 12:00:00 AM | 9/5/2014 10:54 AM |
| Details | State | Update | | Pending | Active | 9/5/2014 10:54 AM |
| Dates | Start Date | Update | | | 10/1/2014 12:00:00 AM | 9/5/2014 10:54 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_46217 | DSH240002A | 9/5/2014 9:22 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_46217 | 7/15/2014 9:52 PM |
| Details | Last Recertification Date | Insert | | | | 7/15/2014 9:52 PM |
| Details | Grant Number | Insert | | | | 7/15/2014 9:52 PM |
| Details | 340B ID | Insert | | | | 7/15/2014 9:52 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/15/2014 9:52 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/15/2014 9:52 PM |
| Details | Medicare Provider Number | Insert | | | 240002 | 7/15/2014 9:52 PM |
| Details | Entity Name | Insert | | | ST. MARY'S MEDICAL CENTER | 7/15/2014 9:52 PM |
| Details | Program Code | Insert | | | DSH | 7/15/2014 9:52 PM |
| Details | Entity Subname | Insert | | | ESSENTIA HEALTH ST MARYS MEDICAL CE | 7/15/2014 9:52 PM |
| Dates | Participating Approval Date | Insert | | | | 7/15/2014 9:52 PM |
| Details | State | Insert | | | Pending | 7/15/2014 9:52 PM |
| Dates | Registration Date | Insert | | | 7/15/2014 12:00:00 AM | 7/15/2014 9:52 PM |
| Dates | Signed By Date | Insert | | | 7/15/2014 12:00:00 AM | 7/15/2014 9:52 PM |
| Dates | Start Date | Insert | | | | 7/15/2014 9:52 PM |
| Terminations | Termination Comments | Insert | | | | 7/15/2014 9:52 PM |
| Terminations | Termination Date | Insert | | | | 7/15/2014 9:52 PM |
| Terminations | Termination Effective Date | Insert | | | | 7/15/2014 9:52 PM |
| Terminations | Termination Reason | Insert | | | | 7/15/2014 9:52 PM |