Covered Entity Details

CAH241357-03 First Care Medical Services (Terminated) - information as of 6/2/2025 8:30:31 AM

Main Details

Name

First Care Medical Services

Subdivision Name

FOSSTON CLINIC / Family Practice

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH241357-03

Medicare Provider Number

241357

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/30/2014

Participating Start Date

1/1/2015

Participating Approval Date

11/13/2014

Last Recertification Date

9/8/2015

Termination Date
Termination Reason

10/1/2015
Other

Contacts

Authorizing Official

Essentia Health
Kimberly Bodensteiner, CFO
(218) 435-7633

Primary Contact

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

Addresses

Street Address

900 HILLIGOSS BLVD SE
Fosston, MN 56542-1542

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
		1497850119

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
CAH241357-01	Child	CAH	FIRST CARE MEDICAL SERVICES	OKLEE	3rd & Governor St.	OKLEE	MN	Terminated
CAH241357-03	Child	CAH	First Care Medical Services	FOSSTON CLINIC / Family Practice	900 HILLIGOSS BLVD SE	Fosston	MN	Terminated
CAH241357-04	Child	CAH	First Care Medical Services	FOSSTON CLINIC / Surgical Ortho	900 HILLIGOSS BLVD SE	Fosston	MN	Terminated
CAH241357-05	Child	CAH	First Care Medical Services	FOSSTON CLINIC / ENT	900 HILLIGOSS BLVD SE	Fosston	MN	Terminated
CAH241357-06	Child	CAH	First Care Medical Services	FOSSTON CLINIC / OB/GYN	900 HILLIGOSS BLVD SE	Fosston	MN	Terminated
CAH241357-07	Child	CAH	First Care Medical Services	FOSSTON CLINIC / Podiatry	900 HILLIGOSS BLVD SE	FOSSTON	MN	Terminated
CAH241357-08	Child	CAH	First Care Medical Services	FOSSTON CLINIC / Hematology/Oncology	900 HILLIGOSS BLVD SE	FOSSTON	MN	Terminated
CAH241357-09	Child	CAH	First Care Medical Services	FOSSTON CLINIC / Cardiology	900 HILLIGOSS BLVD SE	FOSSTON	MN	Terminated
CAH241357-10	Child	CAH	FIRST CARE MEDICAL SERVICES	Essentia Health Bagley Clinic / Family Practice	121 CENTRAL ST W	BAGLEY	MN	Active
CAH241357-11	Child	CAH	FIRST CARE MEDICAL SERVICES	Essentia Health Oklee Clinic / Family Practice	400 GOVERNOR ST	OKLEE	MN	Active
CAH241357-12	Child	CAH	FIRST CARE MEDICAL SERVICES	Essentia Health Bagley Clinic / Psychology	121 CENTRAL ST W	BAGLEY	MN	Active
CAH241357-13	Child	CAH	FIRST CARE MEDICAL SERVICES	Essentia Health Oklee Clinic / Medication Therapy Mgmt - Essentia Health Oklee Clinic / Medication Therapy Mgmt	400 GOVERNOR ST	Oklee	MN	Active
CAH241357-14	Child	CAH	FIRST CARE MEDICAL SERVICES	Essentia Health Bagley Clinic / Medication Therapy Mgmt - Essentia Health Bagley Clinic /Medication Therapy Mgmt	121 CENTRAL ST W	Bagley	MN	Active
CAH241357-15	Child	CAH	FIRST CARE MEDICAL SERVICES	Essentia Health Oklee Clinic / - General Radiology	400 GOVERNOR ST	OKLEE	MN	Active
CAH241357-16	Child	CAH	FIRST CARE MEDICAL SERVICES	Essentia Health Bagley Clinic / - General Radiology	121 CENTRAL STREET W	BAGLEY	MN	Active

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		Bodensteiner, Kimberly CFO 2184357633	Bodensteiner, Kimberly CFO Essentia Health 2184357633	9/22/2017 12:04 PM
Contacts	Signed By	Update		Bodensteiner, Kimberly CFO 2184357633	Bodensteiner, Kimberly CFO Essentia Health 2184357633	9/22/2017 12:04 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	Authorizing Official	Insert			Bodensteiner, Kimberly CFO 2184357633	8/14/2017 9:33 AM
Contacts	Signed By	Insert			Bodensteiner, Kimberly CFO 2184357633	8/14/2017 9:33 AM
Details	Last Recertification Date	Update			9/8/2015 12:00:00 AM	9/8/2015 2:29 PM
Dates	Last Date That 340B Drugs Purchased	Update			9/8/2015 12:00:00 AM	9/8/2015 2:29 PM
Details	State	Update		Active	Terminated	9/8/2015 2:29 PM
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 2:29 PM
Terminations	Termination Date	Update			10/1/2015 12:00:00 AM	9/8/2015 2:29 PM
Terminations	Termination Effective Date	Update			9/8/2015 12:00:00 AM	9/8/2015 2:29 PM
Terminations	Termination Reason	Update			Other	9/8/2015 2:29 PM
Addresses	Main Address	Insert			900 HILLIGOSS BLVD SE Fosston, MN 56542-1542	9/8/2015 2:29 PM
Details	Entity Subname	Update		FOSSTON CLINIC / Family Practice / Family Practice	FOSSTON CLINIC / Family Practice	12/12/2014 11:21 AM
Dates	Participating Approval Date	Update			11/13/2014 12:00:00 AM	11/13/2014 6:43 PM
Details	State	Update		Pending	Active	11/13/2014 6:43 PM
Dates	Start Date	Update			1/1/2015 12:00:00 AM	11/13/2014 6:43 PM
Details	Entity Subname	Update		FOSSTON CLINIC / Family Practice	FOSSTON CLINIC / Family Practice / Family Practice	11/13/2014 6:43 PM
Details	Entity Subname	Update		FOSSTON CLINIC	FOSSTON CLINIC / Family Practice	11/3/2014 9:51 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_47944	CAH241357-03	11/3/2014 9:51 AM
Details	Entity Name	Update		ESSENTIA HEALTH FOSSTON	First Care Medical Services	11/3/2014 9:51 AM
Details	Entity Subname	Update		ESSENTIA HEALTH FOSSTON CLINIC	FOSSTON CLINIC	11/3/2014 9:51 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_47944	10/30/2014 12:41 PM
Medicaid Billing	NPI: Number	Insert			1497850119	10/30/2014 12:41 PM
Details	Last Recertification Date	Insert				10/30/2014 12:41 PM
Details	Grant Number	Insert				10/30/2014 12:41 PM
Details	340B ID	Insert				10/30/2014 12:41 PM
Details	Is Authorizing Official EHB Data	Insert				10/30/2014 12:41 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/30/2014 12:41 PM
Details	Medicare Provider Number	Insert			241357	10/30/2014 12:41 PM
Details	Entity Name	Insert			ESSENTIA HEALTH FOSSTON	10/30/2014 12:41 PM
Details	Program Code	Insert			CAH	10/30/2014 12:41 PM
Details	Entity Subname	Insert			ESSENTIA HEALTH FOSSTON CLINIC	10/30/2014 12:41 PM
Dates	Participating Approval Date	Insert				10/30/2014 12:41 PM
Details	State	Insert			Pending	10/30/2014 12:41 PM
Dates	Registration Date	Insert			10/30/2014 12:00:00 AM	10/30/2014 12:41 PM
Dates	Signed By Date	Insert			10/30/2014 12:00:00 AM	10/30/2014 12:41 PM
Dates	Start Date	Insert				10/30/2014 12:41 PM
Terminations	Termination Comments	Insert				10/30/2014 12:41 PM
Terminations	Termination Date	Insert				10/30/2014 12:41 PM
Terminations	Termination Effective Date	Insert				10/30/2014 12:41 PM
Terminations	Termination Reason	Insert				10/30/2014 12:41 PM