Covered Entity Details

CAH241356-01 MILLE LACS HOSPITAL (Active) - information as of 4/25/2025 6:31:33 PM

Main Details

Name

MILLE LACS HOSPITAL

Subdivision Name

MILLE LACS FAMILY CLINIC - ISLE

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH241356-01

Medicare Provider Number

241356

Outpatient Facility Provider Number

243975

Additional Details

Current Program Status

Active

Registration Date

1/6/2015

Participating Start Date

4/1/2015

Participating Approval Date

2/18/2015

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Mille Lacs Health System
Bill Nelson, CEO
(320) 532-2580

Primary Contact

Mille Lacs Health System
Jennifer McDonnell, Pharmacy Manager
(320) 532-2490

Addresses

Street Address

375 ISLE STREET W
ISLE, MN 56342-2640

Billing Address

Mille Lacs Health System
200 North Elm St
Onamia, MN 56359

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	566354700,190247400,1144242330,1841947801	1497917587,1720163207,1144242330,1841947801,1548212699
WI		1497917587,1720163207
AZ		1497917587,1720163207

Shipping Addresses

Shipping Address 1

Mille Lacs Health System
200 North Elm St
Onamia, MN 56359

Shipping Address 2

Mille Lacs Health System Community Pharmacy - Isle
215 Main St
Isle, MN 56432

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
CAH241356-01	Child	CAH	MILLE LACS HOSPITAL	MILLE LACS FAMILY CLINIC - ISLE	375 ISLE STREET W	ISLE	MN	Active
CAH241356-02	Child	CAH	MILLE LACS HOSPITAL	MILLE LACS FAMILY CLINIC-HILLMAN	26362 370TH AVE	HILLMAN	MN	Active
CAH241356-03	Child	CAH	MILLE LACS HOSPITAL	MILLE LACS FAMILY CLINIC - ONAMIA	200 ELM STREET N	ONAMIA	MN	Active
CAH241356-04	Child	CAH	MILLE LACS HOSPITAL	MILLE LACS HEALTH SYSTEM - RADIOLOGY	27378 STATE HIGHWAY 18	GARRISON	MN	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Change Request		1497917587	9/19/2024 5:14 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	9/19/2024 5:14 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720163207	9/19/2024 5:14 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	9/19/2024 5:14 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1497917587	9/19/2024 5:14 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	9/19/2024 5:14 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720163207	9/19/2024 5:14 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	9/19/2024 5:14 PM
Details	Last Recertification Date	Update	Recertification	8/29/2023 6:29:51 AM	8/12/2024 11:09:38 AM	8/12/2024 11:09 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1548212699	7/10/2024 4:04 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	7/10/2024 4:04 PM
Addresses	Shipping Address	Delete	Recertification	Mille Lacs Health System Community Pharmacy - Isle 205 Main St Isle, MN 56432		8/29/2023 6:29 AM
Addresses	Shipping Address	Insert	Recertification		Mille Lacs Health System Community Pharmacy - Isle 215 Main St Isle, MN 56432	8/29/2023 6:29 AM
Details	Last Recertification Date	Update	Recertification	8/31/2022 10:25:31 AM	8/29/2023 6:29:51 AM	8/29/2023 6:29 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2023 3:11 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841947801	4/3/2023 3:11 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	4/3/2023 3:11 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841947801	4/3/2023 3:11 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	4/3/2023 3:11 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 1:08:30 PM	8/31/2022 10:25:31 AM	8/31/2022 10:25 AM
Addresses	Shipping Address	Insert	Change Request		Mille Lacs Health System Community Pharmacy - Isle 205 Main St Isle, MN 56432	7/15/2022 7:09 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/15/2022 7:09 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1144242330	7/15/2022 7:09 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/15/2022 7:09 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144242330	7/15/2022 7:09 AM
Medicaid Billing	NPI: State	Insert	Change Request		MN	7/15/2022 7:09 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2022 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		566354700	1/14/2022 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	1/14/2022 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2022 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		190247400	1/14/2022 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	1/14/2022 12:16 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720163207	1/14/2022 12:16 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	1/14/2022 12:16 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1497917587	1/7/2022 1:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	1/7/2022 1:25 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 4:01:14 PM	9/7/2021 1:08:30 PM	9/7/2021 1:08 PM
Contacts	Primary Contact	Update	Recertification	Herzog, Francis Pharmacy Director Mille Lacs Health System 3205322494	McDonnell, Jennifer Pharmacy Manager Mille Lacs Health System 3205322490	8/25/2020 4:01 PM
Details	Last Recertification Date	Update	Recertification	8/27/2019 3:08:31 PM	8/25/2020 4:01:14 PM	8/25/2020 4:01 PM
Details	Last Recertification Date	Update	Recertification	8/23/2018 9:45:35 AM	8/27/2019 3:08:31 PM	8/27/2019 3:08 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 2:16:09 PM	8/23/2018 9:45:35 AM	8/23/2018 9:45 AM
Addresses	Billing Address	Insert	Change Request		Mille Lacs Health System 200 North Elm St Onamia, MN 56359	2/13/2018 7:55 AM
Addresses	Shipping Address	Insert	Change Request		Mille Lacs Health System 200 North Elm St Onamia, MN 56359	2/13/2018 7:55 AM
Contacts	Primary Contact	Insert	Recertification		Herzog, Francis Pharmacy Director Mille Lacs Health System 3205322494	11/29/2017 2:16 PM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/29/2017 2:16:09 PM	11/29/2017 2:16 PM
Contacts	Authorizing Official	Update		Nelson, Bill CEO 3205322580	Nelson, Bill CEO Mille Lacs Health System 3205322580	11/29/2017 2:08 PM
Contacts	Signed By	Update		Nelson, Bill CEO 3205322580	Nelson, Bill CEO Mille Lacs Health System 3205322580	11/29/2017 2:08 PM
Contacts	Authorizing Official	Insert			Nelson, Bill CEO 3205322580	5/11/2017 10:09 AM
Contacts	Signed By	Insert			Nelson, Bill CEO 3205322580	5/11/2017 10:09 AM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	9/1/2016 12:00:00 AM	9/1/2016 2:05 PM
Addresses	Main Address	Insert			375 ISLE STREET W ISLE, MN 56342-2640	9/1/2016 2:05 PM
Details	Last Recertification Date	Update			8/5/2015 12:00:00 AM	8/5/2015 10:24 AM
Dates	Participating Approval Date	Update			2/18/2015 12:00:00 AM	2/18/2015 5:37 PM
Details	State	Update		Pending	Active	2/18/2015 5:37 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	2/18/2015 5:37 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_48262	CAH241356-01	1/12/2015 11:44 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_48262	1/6/2015 2:56 PM
Details	Last Recertification Date	Insert				1/6/2015 2:56 PM
Details	Grant Number	Insert				1/6/2015 2:56 PM
Details	340B ID	Insert				1/6/2015 2:56 PM
Details	Is Authorizing Official EHB Data	Insert				1/6/2015 2:56 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/6/2015 2:56 PM
Details	Medicare Provider Number	Insert			241356	1/6/2015 2:56 PM
Details	Entity Name	Insert			MILLE LACS HOSPITAL	1/6/2015 2:56 PM
Details	Program Code	Insert			CAH	1/6/2015 2:56 PM
Details	Entity Subname	Insert			MILLE LACS FAMILY CLINIC - ISLE	1/6/2015 2:56 PM
Dates	Participating Approval Date	Insert				1/6/2015 2:56 PM
Details	State	Insert			Pending	1/6/2015 2:56 PM
Dates	Registration Date	Insert			1/6/2015 12:00:00 AM	1/6/2015 2:56 PM
Dates	Signed By Date	Insert			1/6/2015 12:00:00 AM	1/6/2015 2:56 PM
Dates	Start Date	Insert				1/6/2015 2:56 PM
Terminations	Termination Comments	Insert				1/6/2015 2:56 PM
Terminations	Termination Date	Insert				1/6/2015 2:56 PM
Terminations	Termination Effective Date	Insert				1/6/2015 2:56 PM
Terminations	Termination Reason	Insert				1/6/2015 2:56 PM