Covered Entity Details

CAH241356-02 MILLE LACS HOSPITAL (Active) - information as of 6/9/2025 11:03:25 PM

Main Details

Name

MILLE LACS HOSPITAL

Subdivision Name

MILLE LACS FAMILY CLINIC-HILLMAN

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH241356-02

Medicare Provider Number

241356

Outpatient Facility Provider Number

243434

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
Andrew Jay Knutson, CEO
(320) 532-2580

Primary Contact

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

Addresses

Street Address

26362 370TH AVE
HILLMAN, MN 56338-2349

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	630994100,190247400,1144242330,1841947801	1326200411,1720163207,1144242330,1841947801,1548212699
AZ	210324	1548212699,1720163207,1326200411
WI	1275796773	1548212699,1720163207,1326200411

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 W
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
Contacts	Authorizing Official	Update	Change Request	Nelson, Bill CEO Mille Lacs Health System 3205322580	Knutson, Andrew Jay CEO Mille Lacs Health System 3205322580	4/28/2025 11:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/7/2024 3:38 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		210324	10/7/2024 3:38 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	10/7/2024 3:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/7/2024 3:38 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1275796773	10/7/2024 3:38 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	10/7/2024 3:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1548212699	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		1548212699	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
Medicaid Billing	NPI: Number	Insert	Change Request		1326200411	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		1326200411	9/19/2024 5:14 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	9/19/2024 5:14 PM
Details	Last Recertification Date	Update	Recertification	8/29/2023 11:45:36 AM	8/12/2024 11:10:39 AM	8/12/2024 11:10 AM
Addresses	Shipping Address	Update	Change Request	Mille Lacs Health System Community Pharmacy - Isle 205 Main St Isle, MN 56432	Mille Lacs Health System Community Pharmacy - Isle 215 Main St W Isle, MN 56432	7/10/2024 4:21 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1548212699	7/10/2024 4:21 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	7/10/2024 4:21 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 10:25:18 AM	8/29/2023 11:45:36 AM	8/29/2023 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2023 3:10 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841947801	4/3/2023 3:10 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	4/3/2023 3:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841947801	4/3/2023 3:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	4/3/2023 3:10 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 1:07:08 PM	8/31/2022 10:25:18 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		630994100	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		1326200411	1/7/2022 1:26 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	1/7/2022 1:26 PM
Details	Last Recertification Date	Update	Recertification	9/2/2020 3:30:15 PM	9/7/2021 1:07:08 PM	9/7/2021 1:07 PM
Contacts	Primary Contact	Update	Recertification	Herzog, Francis Pharmacy Director Mille Lacs Health System 3205322494	McDonnell, Jennifer Pharmacy Manager Mille Lacs Health System 3205322490	9/2/2020 3:30 PM
Details	Last Recertification Date	Update	Recertification	8/27/2019 3:08:15 PM	9/2/2020 3:30:15 PM	9/2/2020 3:30 PM
Details	Last Recertification Date	Update	Recertification	8/23/2018 9:46:39 AM	8/27/2019 3:08:15 PM	8/27/2019 3:08 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 2:17:50 PM	8/23/2018 9:46:39 AM	8/23/2018 9:46 AM
Addresses	Billing Address	Insert	Change Request		Mille Lacs Health System 200 North Elm St Onamia, MN 56359	2/13/2018 7:56 AM
Addresses	Shipping Address	Insert	Change Request		Mille Lacs Health System 200 North Elm St Onamia, MN 56359	2/13/2018 7:56 AM
Contacts	Primary Contact	Insert	Recertification		Herzog, Francis Pharmacy Director Mille Lacs Health System 3205322494	11/29/2017 2:17 PM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/29/2017 2:17:50 PM	11/29/2017 2:17 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			26362 370TH AVE HILLMAN, MN 56338-2349	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_48264	CAH241356-02	1/12/2015 11:49 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_48264	1/6/2015 3:05 PM
Details	Last Recertification Date	Insert				1/6/2015 3:05 PM
Details	Grant Number	Insert				1/6/2015 3:05 PM
Details	340B ID	Insert				1/6/2015 3:05 PM
Details	Is Authorizing Official EHB Data	Insert				1/6/2015 3:05 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/6/2015 3:05 PM
Details	Medicare Provider Number	Insert			241356	1/6/2015 3:05 PM
Details	Entity Name	Insert			MILLE LACS HOSPITAL	1/6/2015 3:05 PM
Details	Program Code	Insert			CAH	1/6/2015 3:05 PM
Details	Entity Subname	Insert			MILLE LACS FAMILY CLINIC-HILLMAN	1/6/2015 3:05 PM
Dates	Participating Approval Date	Insert				1/6/2015 3:05 PM
Details	State	Insert			Pending	1/6/2015 3:05 PM
Dates	Registration Date	Insert			1/6/2015 12:00:00 AM	1/6/2015 3:05 PM
Dates	Signed By Date	Insert			1/6/2015 12:00:00 AM	1/6/2015 3:05 PM
Dates	Start Date	Insert				1/6/2015 3:05 PM
Terminations	Termination Comments	Insert				1/6/2015 3:05 PM
Terminations	Termination Date	Insert				1/6/2015 3:05 PM
Terminations	Termination Effective Date	Insert				1/6/2015 3:05 PM
Terminations	Termination Reason	Insert				1/6/2015 3:05 PM