Covered Entity Details

CAH241360-07 ESSENTIA HEALTH DEER RIVER (Terminated) - information as of 6/27/2025 12:32:48 AM

Main Details

Name

ESSENTIA HEALTH DEER RIVER

Subdivision Name

Deer River Healthcare Center- Deer River Clinic / Med Ortho

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH241360-07

Medicare Provider Number

241360

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/14/2014

Participating Start Date

1/1/2015

Participating Approval Date

11/19/2014

Last Recertification Date

9/8/2015

Termination Date
Termination Reason

10/1/2015
Other

Contacts

Authorizing Official

Essentia Health
Steven Feltman, Senior Finance Advisor
(218) 259-8763

Primary Contact

Essentia Health
Bryan Lundberg, 340b Program Manager
(218) 828-7143

Addresses

Street Address

115 10th Avenue NE, Suite A
Deer River, MN 56636

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
		1225049018

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
CAH241360-01	Child	CAH	DEER RIVER HEALTHCARE CENTER	DEER RIVER MERIDIAN MEDICAL CLINIC	1542 GOLF COURSE RD	GRAND RAPIDS	MN	Terminated
CAH241360-02	Child	CAH	DEER RIVER HEALTHCARE CENTER	ESSENTIA HEALTH GRAND RAPIDS CLINIC / Family Practice	1542 GOLF COURSE RD	GRAND RAPIDS	MN	Terminated
CAH241360-03	Child	CAH	ESSENTIA HEALTH DEER RIVER	ESSENTIA HEALTH DEER RIVER CLINIC / Nephrology	115 10TH AVE NE	DEER RIVER	MN	Terminated
CAH241360-04	Child	CAH	ESSENTIA HEALTH DEER RIVER	ESSENTIA HEALTH DEER RIVER CLINIC / Podiatry	115 10TH AVE NE STE A	DEER RIVER	MN	Terminated
CAH241360-05	Child	CAH	ESSENTIA HEALTH DEER RIVER	Deer River Healthcare Center- Deer River Clinic / OB & Gynecology	115 10th Avenue NE, Suite A	Deer River	MN	Terminated
CAH241360-06	Child	CAH	ESSENTIA HEALTH DEER RIVER	Deer River Healthcare Center- Deer River Clinic / Surgery Ortho	115 10th Avenue NE, Suite A	Deer River	MN	Terminated
CAH241360-07	Child	CAH	ESSENTIA HEALTH DEER RIVER	Deer River Healthcare Center- Deer River Clinic / Med Ortho	115 10th Avenue NE, Suite A	Deer River	MN	Terminated
CAH241360-08	Child	CAH	ESSENTIA HEALTH DEER RIVER	Deer River Healthcare Center- Deer River Clinic / Fam/Genl Practice	115 10th Avenue NE, Suite A	Deer River	MN	Terminated
CAH241360-09	Child	CAH	DEER RIVER HEALTHCARE CENTER	ESSENTIA HEALTH GRAND RAPIDS CLINIC / Non Invasive	1542 GOLF COURSE RD STE 203	Grand Rapids	MN	Terminated
CAH241360-10	Child	CAH	DEER RIVER HEALTHCARE CENTER INC	Essentia Health Remer Clinic / Family Practice	9 BIRCH ST NE	REMER	MN	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
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
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
Contacts	Authorizing Official	Update	AO Change Request	Green, Marsha COO Essentia Health 2182464200	Feltman, Steven Senior Finance Advisor Essentia Health 2182598763	5/10/2019 9:27 AM
Contacts	Signed By	Update		Jacobson, Terry Administrator 7158177014	Jacobson, Terry Administrator Essentia Health 7158177014	11/22/2017 4:08 PM
Contacts	Authorizing Official	Update		Green, Marsha COO 2182464200	Green, Marsha COO Essentia Health 2182464200	9/22/2017 2:05 PM
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	Signed By	Insert			Jacobson, Terry Administrator 7158177014	8/2/2017 3:07 PM
Contacts	Authorizing Official	Insert			Green, Marsha COO 2182464200	2/16/2017 4:22 PM
Details	Last Recertification Date	Update			9/8/2015 12:00:00 AM	9/8/2015 10:53 AM
Dates	Last Date That 340B Drugs Purchased	Update			9/8/2015 12:00:00 AM	9/8/2015 10:53 AM
Details	State	Update		Active	Terminated	9/8/2015 10:53 AM
Terminations	Termination Comments	Update			I am terminating the Child Site due to it having the same physical address as Parent Site. According to Apexus/HRSA we do not need it registered on the database. This Child Site would remain eligible as it is considered within the 4 walls of the hospital.	9/8/2015 10:53 AM
Terminations	Termination Date	Update			10/1/2015 12:00:00 AM	9/8/2015 10:53 AM
Terminations	Termination Effective Date	Update			9/8/2015 12:00:00 AM	9/8/2015 10:53 AM
Terminations	Termination Reason	Update			Other	9/8/2015 10:53 AM
Addresses	Main Address	Insert			115 10th Avenue NE, Suite A Deer River, MN 56636	9/8/2015 10:53 AM
Details	Entity Subname	Update		Deer River Healthcare Center- Deer River Clinic / Med Ortho / Med Ortho	Deer River Healthcare Center- Deer River Clinic / Med Ortho	12/12/2014 11:21 AM
Details	Entity Subname	Update		Deer River Healthcare Center- Deer River Clinic / Med Ortho	Deer River Healthcare Center- Deer River Clinic / Med Ortho / Med Ortho	11/19/2014 6:31 AM
Dates	Participating Approval Date	Update			11/19/2014 12:00:00 AM	11/19/2014 6:31 AM
Details	State	Update		Pending	Active	11/19/2014 6:31 AM
Dates	Start Date	Update			1/1/2015 12:00:00 AM	11/19/2014 6:31 AM
Details	Entity Subname	Update		Deer River Healthcare Center- Deer River Clinic	Deer River Healthcare Center- Deer River Clinic / Med Ortho	11/18/2014 10:24 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_47263	CAH241360-07	11/18/2014 10:24 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_47263	10/14/2014 11:54 AM
Medicaid Billing	NPI: Number	Insert			1225049018	10/14/2014 11:54 AM
Details	Last Recertification Date	Insert				10/14/2014 11:54 AM
Details	Grant Number	Insert				10/14/2014 11:54 AM
Details	340B ID	Insert				10/14/2014 11:54 AM
Details	Is Authorizing Official EHB Data	Insert				10/14/2014 11:54 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/14/2014 11:54 AM
Details	Medicare Provider Number	Insert			241360	10/14/2014 11:54 AM
Details	Entity Name	Insert			ESSENTIA HEALTH DEER RIVER	10/14/2014 11:54 AM
Details	Program Code	Insert			CAH	10/14/2014 11:54 AM
Details	Entity Subname	Insert			Deer River Healthcare Center- Deer River Clinic	10/14/2014 11:54 AM
Dates	Participating Approval Date	Insert				10/14/2014 11:54 AM
Details	State	Insert			Pending	10/14/2014 11:54 AM
Dates	Registration Date	Insert			10/14/2014 12:00:00 AM	10/14/2014 11:54 AM
Dates	Signed By Date	Insert			10/14/2014 12:00:00 AM	10/14/2014 11:54 AM
Dates	Start Date	Insert				10/14/2014 11:54 AM
Terminations	Termination Comments	Insert				10/14/2014 11:54 AM
Terminations	Termination Date	Insert				10/14/2014 11:54 AM
Terminations	Termination Effective Date	Insert				10/14/2014 11:54 AM
Terminations	Termination Reason	Insert				10/14/2014 11:54 AM