Covered Entity Details

DSH240057P ABBOTT NORTHWESTERN HOSPITAL (Active) - information as of 6/9/2025 12:02:35 AM

Main Details

Name

ABBOTT NORTHWESTERN HOSPITAL

Subdivision Name

Allina Health Cancer Institute - Piper Breast Plymouth

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240057P

Medicare Provider Number

240057

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/15/2015

Participating Start Date

10/1/2015

Participating Approval Date

7/23/2015

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Allina Health
Tony M Collins-Kwong, Director, Strategic Sourcing and Services, Pharmacy Services
(612) 262-4785

Primary Contact

Allina Health
Jeremy Enger, 340B Program Manager
(612) 760-7836

Addresses

Street Address

2855 Campus Drive
150
Plymouth, MN 55441

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
MN	298463300,137745101,137745102,524142000,995318301,137745100	1760446256,1750346243,1679537666,1437713583,1316901333,1700840097,1295799518,1780648964,1598822686,1760446124,1942264270,1780094698,1063449213,1699739045,1851355135,1104880384,1982641346
WI	298463300,137745101,137745102,524142000,995318301,137745100	1760446256,1750346243,1679537666,1437713583

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
Contract Detail	ALLINA HEALTH APPLE VALLEY PHARMACY	14655 GALAXIE AVE		APPLE VALLEY	MN	55124-8602	12/01/2023	01/01/2024	01/01/2024		01/01/2024
Contract Detail	ALLINA HEALTH CAMBRIDGE PHARMACY	701 DELLWOOD ST S		CAMBRIDGE	MN	55008-1920	04/12/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH COTTAGE GROVE PHARMACY	8611 W POINT DOUGLAS RD S		COTTAGE GROVE	MN	55016-4005	12/01/2023	01/01/2024	01/01/2024		01/01/2024
Contract Detail	ALLINA HEALTH FARIBAULT PHARMACY	200 STATE AVE		FARIBAULT	MN	55021	04/12/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH HEART HOSPITAL PHARMACY	920 E 28TH ST STE H1254		MINNEAPOLIS	MN	55407	10/02/2015	01/01/2016	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH MERCY PHARMACY	11850 BLACKFOOT ST. NW	STE 190	COON RAPIDS	MN	55433	04/12/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH NEW ULM PHARMACY	1217 8TH ST N STE 1010		NEW ULM	MN	56073-1552	04/12/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH PHILLIPS EYE INSTITUTE PHA	2215 PARK AVE SOUTH		MINNEAPOLIS	MN	55404	04/12/2021	07/01/2021		03/25/2022	12/01/2023
Contract Detail	ALLINA HEALTH PIPER BUILDING PHARMACY	913 E 26TH ST	1ST FLOOR PIPER BUILDING	MINNEAPOLIS	MN	55404	10/02/2015	01/01/2016	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH ST. FRANCIS PHARMACY	1455 SAINT FRANCIS AVE STE 100		SHAKOPEE	MN	55379-3374	04/12/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH UNITED PHARMACY	333 SMITH AVE N		SAINT PAUL	MN	55102-2344	04/12/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH UNITY PHARMACY	550 OSBORNE RD NE		FRIDLEY	MN	55432-2718	04/12/2021	07/01/2021	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH WESTHEALTH PHARMACY	2855 CAMPUS DR		PLYMOUTH	MN	55441	10/02/2015	01/01/2016	01/01/2024		12/04/2023
Contract Detail	ALLINA HEALTH WOODBURY PHARMACY	8675 VALLEY CREEK RD		WOODBURY	MN	55125-2337	12/01/2023	01/01/2024	01/01/2024		01/01/2024
Contract Detail	MERCY HOSPITAL PHC	4050 COON RAPIDS BLVD NW		COON RAPIDS	MN	55433-2522	01/17/2017	04/01/2017			01/17/2017

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH240057A	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Abbott Northwestern WestHealth Emergency Dept	2855 Campus Drive	Plymouth	MN	Active
DSH240057AA	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Phillips Eye Institute Diagnostic/Refractive - Optometry	2215 Park Avenue	Minneapolis	MN	Terminated
DSH240057AB	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Allina Health Mental Health - Abbott Northwestern Clinic	2855 Campus Drive	Plymouth	MN	Active
DSH240057AC	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	AMHS Abbott Northwestern Outpatient Clinic - Mental Health	800 E. 28th Street	Minneapolis	MN	Active
DSH240057AD	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Phillips Eye institute Operating Room - Optometry - Surgery	2215 Park Avenue	Minneapolis	MN	Terminated
DSH240057AE	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Ramsey	7231 Sunwood Dr NW	Ramsey	MN	Active
DSH240057AF	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Champlin	11269 Jefferson Hwy	Champlin	MN	Active
DSH240057AG	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Elk River	14181 Business Center Dr NW	Elk River	MN	Active
DSH240057AH	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Institute-Abbott	800 E 28th St	Minneapolis	MN	Active
DSH240057AJ	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Allina Health Cancer Institute - Piper Breast Minneapolis	913 E 26th St	Minneapolis	MN	Active
DSH240057AK	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Allina Health Cancer Institute - Abbott Northwestern Hospital	800 E. 28th Street	Minneapolis	MN	Active
DSH240057AL	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Fridley	500 Osborne Rd NE	Fridley	MN	Active
DSH240057AM	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Phillips Eye Institute Professional Services - Low Vision Clinic	710 E. 24th Street	Minneapolis	MN	Terminated
DSH240057AN	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Minnesota Perinatal Physicians Abbott	902 E 26th St	Minneapolis	MN	Active
DSH240057AP	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Institute - Golden Valley	3915 Golden Valley Road	Golden Valley	MN	Active
DSH240057AQ	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Richfield	6601 Lyndale Ave S	Richfield	MN	Active
DSH240057AR	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Maple Grove	7840 Vinewood Ln N	Maple Grove	MN	Active
DSH240057AS	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-BSQ	1021 Bandana Blvd E	St Paul	MN	Active
DSH240057AT	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Cottage Grove	8811 92nd St S	Cottage Grove	MN	Active
DSH240057AU	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Edina	8100 W 78th St	Edina	MN	Active
DSH240057AV	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Shoreview	4180 N Lexington Ave	Shoreview	MN	Active
DSH240057AW	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Springbrook	9055 Springbrook Dr NW	Coon Rapids	MN	Active
DSH240057AX	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Vadnais Heights	1155 East County Rd E	Vadnais Heights	MN	Active
DSH240057AY	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Eagan	1284 Corporate Center Dr	Eagan	MN	Active
DSH240057AZ	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Institute - Forest Lake	1467 Lake St S	Forest Lake	MN	Active
DSH240057B	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Minnesota Perinatal Physicians Maple Grove / MG Perinatal Ultrasound	9600 Upland Lane N	Maple Grove	MN	Terminated
DSH240057BA	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Associates	800 E. 28th Street	Minneapolis	MN	Active
DSH240057BB	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Institute - Burnsville	12400 Portland Ave S	Burnsville	MN	Active
DSH240057BC	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Institute-Peds	1111 Holcombe St S	Stillwater	MN	Active
DSH240057BD	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Minneapolis	2800 Chicago Ave	Minneapolis	MN	Active
DSH240057BE	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Woodbury - Lymphedema	1625 Radio Dr	Woodbury	MN	Terminated
DSH240057BF	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Associates - MH	800 E 28th St	Minneapolis	MN	Terminated
DSH240057BG	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Allina Health Cancer Institute - Piper Breast Minneapolis - Oncology	913 E 26th St	Minneapolis	MN	Active
DSH240057C	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Minnesota Perinatal Physicians Maple Grove / MG High Risk Perinatal Clinic	9600 Upland Lane N	Maple Grove	MN	Terminated
DSH240057D	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Minnesota Perinatal Physicians Edina	6525 France Ave S	Edina	MN	Active
DSH240057E	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Minnesota Perinatal Physicians Edina / SW Perinatal Ultrasound	6525 France Ave Sout	Edina	MN	Terminated
DSH240057F	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Associates Pain Program	3915 Golden Valley Road	Golden Valley	MN	Active
DSH240057G	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Associates Pain Clinic & Pain Program / Pain Clinic	3915 Golden Valley Road	Golden Valley	MN	Terminated
DSH240057H	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Associates	7373 France Avenue S	Edina	MN	Active
DSH240057J	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Doctor's Professional Bldg	280 N. Smith Avenue	St. Paul	MN	Active
DSH240057K	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy - Plymouth	2805 Campus Drive	Plymouth	MN	Active
DSH240057L	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Associates / Mental Health	3915 Golden Valley Road	Golden Valley	MN	Active
DSH240057M	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Associates / Primary Care	3915 Golden Valley Road	Golden Valley	MN	Active
DSH240057N	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Associates / Spine	3915 Golden Valley Road	Golden Valley	MN	Active
DSH240057P	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Allina Health Cancer Institute - Piper Breast Plymouth	2855 Campus Drive	Plymouth	MN	Active
DSH240057Q	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Abbott Northwestern WestHealth Imaging	2855 Campus Drive	Plymouth	MN	Active
DSH240057R	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Institute-Centennial Lakes	7373 France Avenue South	Edina	MN	Active
DSH240057S	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Woodbury	1625 Radio Drive	Woodbury	MN	Active
DSH240057T	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Plymouth	2805 Campus Drive	Plymouth	MN	Terminated
DSH240057U	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Sports & Physical Therapy-Coon Rapids, Mercy Specialty Center	11850 Blackfoot Street NW	Coon Rapids	MN	Active
DSH240057V	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Courage Kenny Rehab Institute-Stillwater	1460 Curve Crest Boulevard	Stillwater	MN	Active
DSH240057W	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Post Transplant Services - Transplant	920 E. 28th Street	Minneapolis	MN	Terminated
DSH240057X	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	VPCI Clinics - Oncology	913 E. 26th Street	Minneapolis	MN	Terminated
DSH240057Y	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Abbott Northwestern Kidney Transplant Providers	920 E. 28th Street	Minneapolis	MN	Active
DSH240057Z	Child	DSH	ABBOTT NORTHWESTERN HOSPITAL	Phillips Eye Institute Anesthesia - Anesthesia	2215 Park Avenue	Minneapolis	MN	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 11:11:50 AM	8/12/2024 5:54:30 PM	8/12/2024 5:54 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1316901333	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700840097	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1295799518	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1780648964	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1598822686	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760446124	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1942264270	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1780094698	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1063449213	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1699739045	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1851355135	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104880384	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1982641346	6/17/2024 2:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:05 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 8:47:34 AM	8/16/2023 11:11:50 AM	8/16/2023 11:11 AM
Details	Last Recertification Date	Update	Recertification	9/10/2021 9:16:26 AM	9/6/2022 8:47:34 AM	9/6/2022 8:47 AM
Details	Entity Subname	Update	Recertification	AHCI - Piper Breast Plymouth	Allina Health Cancer Institute - Piper Breast Plymouth	9/6/2022 8:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		524142000	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		995318301	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		137745100	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		524142000	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		995318301	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		137745100	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	7/8/2022 8:47 AM
Details	Entity Subname	Update	Change Request	Piper Breast Center - WestHealth	AHCI - Piper Breast Plymouth	7/8/2022 8:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 9:01 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		137745101	4/12/2022 9:01 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MN	4/12/2022 9:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 9:01 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		137745101	4/12/2022 9:01 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 9:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 9:01 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		137745102	4/12/2022 9:01 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MN	4/12/2022 9:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/12/2022 9:01 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		137745102	4/12/2022 9:01 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	4/12/2022 9:01 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1750346243	4/12/2022 9:01 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	4/12/2022 9:01 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1750346243	4/12/2022 9:01 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	4/12/2022 9:01 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679537666	4/12/2022 9:01 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	4/12/2022 9:01 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679537666	4/12/2022 9:01 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	4/12/2022 9:01 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1437713583	4/12/2022 9:01 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	4/12/2022 9:01 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1437713583	4/12/2022 9:01 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	4/12/2022 9:01 AM
Contacts	Authorizing Official	Update	Change Request	Collins-Kwong, Tony Director, Strategic Sourcing and Services, Pharmacy Services Allina Health 6122624785	Collins-Kwong, Tony M Director, Strategic Sourcing and Services, Pharmacy Services Allina Health 6122624785	3/22/2022 11:12 AM
Addresses	Main Address	Update	Recertification	2855 Campus Drive Plymouth, MN 55441	2855 Campus Drive 150 Plymouth, MN 55441	9/10/2021 9:16 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1073040408 (MN)		9/10/2021 9:16 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1073040408 (WI)		9/10/2021 9:16 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1760446256	9/10/2021 9:16 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/10/2021 9:16 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1760446256	9/10/2021 9:16 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/10/2021 9:16 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 11:23:24 AM	9/10/2021 9:16:26 AM	9/10/2021 9:16 AM
Details	Entity Subname	Update	Recertification	Abbott Northwestern WestHealth Imaging (includes Piper Breast)	Piper Breast Center - WestHealth	9/10/2021 9:16 AM
Contacts	Authorizing Official	Update	Profile Change Request	Collins-Kwong, Tony Pharmacy Services Portfolio Manager Allina Health 6122624785	Collins-Kwong, Tony Director, Strategic Sourcing and Services, Pharmacy Services Allina Health 6122624785	8/23/2021 8:02 AM
Contacts	Authorizing Official	Update	Change Request	Rice, Ann President Abbott Northwestern Hospital 6128637737	Collins-Kwong, Tony Pharmacy Services Portfolio Manager Allina Health 6122624785	8/17/2021 7:34 AM
Contacts	Primary Contact	Update	Group Change Request	Collins-Kwong, Tony Pharmacy Services Portfolio Manager Allina Health 6122624785	Enger, Jeremy 340B Program Manager Allina Health 6127607836	8/13/2021 12:55 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	137745100 (MN)		9/8/2020 11:23 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 11:23 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		298463300	9/8/2020 11:23 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	9/8/2020 11:23 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 11:23 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		298463300	9/8/2020 11:23 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	240057 (MN)		9/8/2020 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	240057 (IA)		9/8/2020 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	240057 (ND)		9/8/2020 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	240057 (WI)		9/8/2020 11:23 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073040408	9/8/2020 11:23 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/8/2020 11:23 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073040408	9/8/2020 11:23 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 11:23 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1760446256 ( )		9/8/2020 11:23 AM
Details	Last Recertification Date	Update	Recertification	9/5/2019 2:11:43 PM	9/8/2020 11:23:24 AM	9/8/2020 11:23 AM
Details	Last Recertification Date	Update	Recertification	9/4/2018 2:14:46 PM	9/5/2019 2:11:43 PM	9/5/2019 2:11 PM
Contacts	Authorizing Official	Update	Change Request	Beitzel, Earl Kenneth VP, Finance Abbott Northwestern Hospital Alllina Health 6128631920	Rice, Ann President Abbott Northwestern Hospital 6128637737	7/1/2019 6:47 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	240057 (SD)		3/28/2019 5:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/14/2018 2:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		137745100	9/14/2018 2:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	9/14/2018 2:17 PM
Details	Last Recertification Date	Update	Recertification	11/14/2017 3:35:14 PM	9/4/2018 2:14:46 PM	9/4/2018 2:14 PM
Contacts	Authorizing Official	Update	Change Request	Weinreis, Brian Chief Financial Officer Allina Health 6128631920	Beitzel, Earl Kenneth VP, Finance Abbott Northwestern Hospital Alllina Health 6128631920	2/13/2018 10:57 AM
Contacts	Primary Contact	Insert	Recertification		Collins-Kwong, Tony Pharmacy Services Portfolio Manager Allina Health 6122624785	11/14/2017 3:35 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/14/2017 3:35:14 PM	11/14/2017 3:35 PM
Contacts	Authorizing Official	Update		Weinreis, Brian Chief Financial Officer 6128631920	Weinreis, Brian Chief Financial Officer Allina Health 6128631920	11/14/2017 3:06 PM
Contacts	Signed By	Update		Weinreis, Brian Chief Financial Officer 6128631920	Weinreis, Brian Chief Financial Officer Allina Health 6128631920	11/14/2017 3:06 PM
Contacts	Authorizing Official	Insert			Weinreis, Brian Chief Financial Officer 6128631920	1/17/2017 12:28 PM
Contacts	Signed By	Insert			Weinreis, Brian Chief Financial Officer 6128631920	1/17/2017 12:28 PM
Addresses	Main Address	Insert			2855 Campus Drive Plymouth, MN 55441	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: Number	Insert			240057	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: State	Insert			IA	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: Number	Insert			240057	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: State	Insert			ND	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: Number	Insert			240057	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: State	Insert			SD	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: Number	Insert			240057	8/30/2016 10:37 AM
Medicaid Billing	Medicaid: State	Insert			WI	8/30/2016 10:37 AM
Details	Last Recertification Date	Update			8/30/2016 12:00:00 AM	8/30/2016 10:37 AM
Dates	Participating Approval Date	Update			7/23/2015 12:00:00 AM	7/23/2015 5:01 PM
Details	State	Update		Pending	Active	7/23/2015 5:01 PM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	7/23/2015 5:01 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_53985	DSH240057P	7/23/2015 3:05 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_53985	7/15/2015 4:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/15/2015 4:11 PM
Medicaid Billing	Medicaid: Number	Insert			240057	7/15/2015 4:11 PM
Medicaid Billing	Medicaid: State	Insert			MN	7/15/2015 4:11 PM
Medicaid Billing	NPI: Number	Insert			1760446256	7/15/2015 4:11 PM
Details	Last Recertification Date	Insert				7/15/2015 4:11 PM
Details	Grant Number	Insert				7/15/2015 4:11 PM
Details	340B ID	Insert				7/15/2015 4:11 PM
Details	Is Authorizing Official EHB Data	Insert				7/15/2015 4:11 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/15/2015 4:11 PM
Details	Medicare Provider Number	Insert			240057	7/15/2015 4:11 PM
Details	Entity Name	Insert			ABBOTT NORTHWESTERN HOSPITAL	7/15/2015 4:11 PM
Details	Program Code	Insert			DSH	7/15/2015 4:11 PM
Details	Entity Subname	Insert			Abbott Northwestern WestHealth Imaging (includes Piper Breast)	7/15/2015 4:11 PM
Dates	Participating Approval Date	Insert				7/15/2015 4:11 PM
Details	State	Insert			Pending	7/15/2015 4:11 PM
Dates	Registration Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 4:11 PM
Dates	Signed By Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 4:11 PM
Dates	Start Date	Insert				7/15/2015 4:11 PM
Terminations	Termination Comments	Insert				7/15/2015 4:11 PM
Terminations	Termination Date	Insert				7/15/2015 4:11 PM
Terminations	Termination Effective Date	Insert				7/15/2015 4:11 PM
Terminations	Termination Reason	Insert				7/15/2015 4:11 PM