Covered Entity Details

DSH240036R ST. CLOUD HOSPITAL (Terminated) - information as of 5/27/2025 11:41:34 PM

Main Details

Name

ST. CLOUD HOSPITAL

Subdivision Name

Dialysis - Saint Cloud

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH240036R

Medicare Provider Number

240036

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/4/2016

Participating Start Date

7/1/2016

Participating Approval Date

4/21/2016

Last Recertification Date

8/16/2021

Termination Date
Termination Reason

7/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

CentraCare
Michael Allan Blair, Chief Financial Officer
(320) 255-5665

Primary Contact

St Cloud Hospital
Mary Phipps, Senior Director Pharmacy
(320) 251-2700 Ext: 71287

Addresses

Street Address

2035 15th Street North
220
Saint Cloud, MN 56303

Billing Address

Saint Cloud Hospital
1406 Sixth Avenue North
Saint Cloud, MN 56303

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	1629027123,1821047317	1629027123,1821047317

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
DSH240036A	Child	DSH	ST. CLOUD HOSPITAL	Women & Children's Center	1900 CentraCare Circle	Saint Cloud	MN	Terminated
DSH240036AA	Child	DSH	ST. CLOUD HOSPITAL	CENTRACARE WOUND CENTER	2035 15TH Street North	Saint Cloud	MN	Active
DSH240036AB	Child	DSH	ST. CLOUD HOSPITAL	SCH - BHC General Adult Psychiatry	1900 CentraCare Circle	Saint Cloud	MN	Active
DSH240036AC	Child	DSH	ST. CLOUD HOSPITAL	Addiction Medicine Clinic	3701 12th Street North	Saint Cloud	MN	Active
DSH240036AD	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Child/Adolescent Special	1900 Centracare Circle	Saint Cloud	MN	Terminated
DSH240036AE	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Acute	1406 Sixth Avenue North	Saint Cloud	MN	Terminated
DSH240036AF	Child	DSH	ST. CLOUD HOSPITAL	Perinatal Clinic	1406 Sixth Avenue North	Saint Cloud	MN	Terminated
DSH240036AG	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Radiation Oncology Clinic	1900 Centracare Circle	Saint Cloud	MN	Active
DSH240036AH	Child	DSH	ST. CLOUD HOSPITAL	Dialysis-Peritoneal	2035 15th Street North	Saint Cloud	MN	Terminated
DSH240036AJ	Child	DSH	ST. CLOUD HOSPITAL	Plaza Imaging Nuclear Medicine	1900 Centracare Circle	Saint Cloud	MN	Active
DSH240036AK	Child	DSH	ST. CLOUD HOSPITAL	Plaza - BHC Child/Adol Psychiatry	1564 County Road 134	Saint Cloud	MN	Active
DSH240036AL	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Women's Center Behavioral Health	1900 Centracare Circle	Saint Cloud	MN	Terminated
DSH240036AM	Child	DSH	ST. CLOUD HOSPITAL	Plaza-Imaging CT Scanning	1900 Centracare Circle	Saint Cloud	MN	Active
DSH240036AN	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Imaging MRI	1900 Centracare Circle	Saint Cloud	MN	Active
DSH240036AP	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Peds Occupational Therapy Outpatient	1900 Centracare Circle	Saint Cloud	MN	Terminated
DSH240036AQ	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Adult Occupational Therapy Outpatient	1900 Centracare Circle	Saint Cloud	MN	Terminated
DSH240036AR	Child	DSH	ST. CLOUD HOSPITAL	Sleep Center	1586 County Road 134	Saint Cloud	MN	Active
DSH240036AS	Child	DSH	ST. CLOUD HOSPITAL	CLARAS HOUSE - A&C Outpatient	1564 COUNTY ROAD 134	ST CLOUD	MN	Active
DSH240036AT	Child	DSH	ST. CLOUD HOSPITAL	PASSAGES - SCH Recovery Plus	121 PARK AVENUE S	ST CLOUD	MN	Terminated
DSH240036AU	Child	DSH	ST. CLOUD HOSPITAL	JOURNEY HOME - A&C Outpatient	1485 10TH AVENUE NE	SAUK RAPIDS	MN	Terminated
DSH240036AV	Child	DSH	ST. CLOUD HOSPITAL	Dialysis-Olivia - Dialysis	600 East Park Avenue	Olivia	MN	Terminated
DSH240036AW	Child	DSH	ST. CLOUD HOSPITAL	Plaza Rheumatology - Rheumatology	1900 CentraCare Circle	Saint Cloud	MN	Active
DSH240036AX	Child	DSH	ST. CLOUD HOSPITAL	Saint Cloud Hospital Plaza Gastroenterology - Gastroenterology	1900 CentraCare Circle	Saint Cloud	MN	Active
DSH240036AY	Child	DSH	ST. CLOUD HOSPITAL	St. Cloud Hospital Dialysis - Aitkin - Dialysis - Dialysis	200 Bunker Hill Drive	Aitkin	MN	Terminated
DSH240036B	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Physiatry	1900 CentraCare Circle	Saint Cloud	MN	Active
DSH240036C	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Chemo/Infusion	1900 CentraCare Circle	Saint Cloud	MN	Active
DSH240036D	Child	DSH	ST. CLOUD HOSPITAL	Outpatient Services	1406 Sixth Avenue North	Saint Cloud	MN	Terminated
DSH240036E	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Imaging Diagnostic	1900 CentraCare Circle	Saint Cloud	MN	Active
DSH240036F	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Endoscopy	1900 CentraCare Circle	Saint Cloud	MN	Active
DSH240036G	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Brainerd	2024 South Sixth Street	Brainerd	MN	Terminated
DSH240036H	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Alexandria	111 17th Avenue East	Alexandria	MN	Terminated
DSH240036J	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Little Falls	808 Third Street Southeast	Little Falls	MN	Terminated
DSH240036K	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Staples	403 Prairie Avenue Northeast	Staples	MN	Terminated
DSH240036L	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Princeton	112 South Rum River Drive	Princeton	MN	Terminated
DSH240036M	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Cambridge	520 11th Avenue Southwest	Cambridge	MN	Terminated
DSH240036N	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Litchfield	520 US Highway 12 East	Litchfield	MN	Terminated
DSH240036P	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Home Hemodialysis	2035 15th Street North	Saint Cloud	MN	Terminated
DSH240036Q	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Big Lake	16830 198th Avenue Northwest	Big Lake	MN	Terminated
DSH240036R	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Saint Cloud	2035 15th Street North	Saint Cloud	MN	Terminated
DSH240036S	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Adult Physical Therapy Outpatient	1900 Centracare circle	Saint Cloud	MN	Terminated
DSH240036T	Child	DSH	ST. CLOUD HOSPITAL	Plaza - BHC Child/Adol Psychology	1900 Centracare Circle	Saint Cloud	MN	Active
DSH240036U	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Radiation Oncology	1900 Centracare Circle	Saint Cloud	MN	Active
DSH240036V	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Medical Oncology Clinic	1900 Centracare Circle	Saint Cloud	MN	Active
DSH240036W	Child	DSH	ST. CLOUD HOSPITAL	Dialysis - Nocturnal	2035 15th Street North	Saint Cloud	MN	Terminated
DSH240036X	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Peds Physical Therapy Outpatient	1900 Centracare Circle	Saint Cloud	MN	Terminated
DSH240036Y	Child	DSH	ST. CLOUD HOSPITAL	Plaza - Imaging Breast Center	1900 CentraCare Circle	Saint Cloud	MN	Active
DSH240036Z	Child	DSH	ST. CLOUD HOSPITAL	Plaza - BHC General Adult Psychology - Behavorial Health	3701 12th Street North	Saint Cloud	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/31/2021 12:00:00 AM	4/6/2022 7:03 AM
Details	State	Update	Termination Request	Active	To Be Terminated	4/6/2022 7:03 AM
Terminations	Termination Date	Update	Termination Request		7/1/2022 12:00:00 AM	4/6/2022 7:03 AM
Terminations	Termination Effective Date	Update	Termination Request		9/1/2021 12:00:00 AM	4/6/2022 7:03 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	4/6/2022 7:03 AM
Details	Last Recertification Date	Update	Recertification	8/25/2020 12:11:32 PM	8/16/2021 9:35:07 AM	8/16/2021 9:35 AM
Contacts	Authorizing Official	Update	AO Change Request	Otto, Kurt Tyler Vice President Operations, Specialty Division St. Cloud Hospital 3202512700-55971	Blair, Michael Allan Chief Financial Officer CentraCare 3202555665	12/7/2020 9:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1629027123	8/25/2020 12:11 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1821047317	8/25/2020 12:11 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	883747300 (MN)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	016057 (AZ)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	95094306 (CO)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	90932700 (FL)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	612061 (HI)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100040030 (IN)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0914713 (IA)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100396970 (KS)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1409235 (LA)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	4719555 (MI)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	00939027 (MS)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	82539367 (NM)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100692650 (OK)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	5525040 (SD)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	3114600 (WA)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	80583100 (WI)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	109288000 (WY)		8/25/2020 12:11 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1461848 (ND)		8/25/2020 12:11 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	8/25/2020 12:11 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	8/25/2020 12:11 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 2:08:38 PM	8/25/2020 12:11:32 PM	8/25/2020 12:11 PM
Contacts	Primary Contact	Update	Profile Change Request	Phipps, Mary Director System Pharmacy St Cloud Hospital 3202512700-71287	Phipps, Mary Senior Director Pharmacy St Cloud Hospital 3202512700-71287	8/18/2020 10:49 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821047317	3/27/2020 1:23 PM
Details	Last Recertification Date	Update	Recertification	8/17/2018 4:17:32 PM	8/20/2019 2:08:38 PM	8/20/2019 2:08 PM
Details	Last Recertification Date	Update	Recertification	11/15/2017 9:47:05 PM	8/17/2018 4:17:32 PM	8/17/2018 4:17 PM
Addresses	Main Address	Update	Recertification	2035 15th Street North Saint Cloud, MN 56303	2035 15th Street North 220 Saint Cloud, MN 56303	11/15/2017 9:47 PM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/15/2017 9:47:05 PM	11/15/2017 9:47 PM
Contacts	Authorizing Official	Insert	Change Request		Otto, Kurt Tyler Vice President Operations, Specialty Division St. Cloud Hospital 3202512700-55971	10/18/2017 6:57 AM
Contacts	Signed By	Update		Klugherz, Greg CFO 3202555655	Klugherz, Greg CFO St. Cloud Hospital 3202555655	10/9/2017 10:28 AM
Contacts	Primary Contact	Update		Phipps, Mary Director System Pharmacy 3202512700-71287	Phipps, Mary Director System Pharmacy St Cloud Hospital 3202512700-71287	10/6/2017 2:04 PM
Contacts	Signed By	Insert			Klugherz, Greg CFO 3202555655	7/13/2017 12:50 PM
Contacts	Primary Contact	Update		Hagen, Jennifer Director Ambulatory Pharmacy Services 3202295199-70979	Phipps, Mary Director System Pharmacy 3202512700-71287	9/20/2016 12:54 AM
Addresses	Main Address	Insert			2035 15th Street North Saint Cloud, MN 56303	9/8/2016 5:35 PM
Addresses	Billing Address	Insert			Saint Cloud Hospital 1406 Sixth Avenue North Saint Cloud, MN 56303	9/8/2016 5:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/8/2016 5:35 PM
Medicaid Billing	Medicaid: Number	Insert			1461848	9/8/2016 5:35 PM
Medicaid Billing	Medicaid: State	Insert			ND	9/8/2016 5:35 PM
Medicaid Billing	NPI: Number	Insert			1629027123	8/18/2016 1:00 PM
Details	Last Recertification Date	Update			8/18/2016 12:00:00 AM	8/18/2016 1:00 PM
Contacts	Primary Contact	Insert			Hagen, Jennifer Director Ambulatory Pharmacy Services 3202295199-70979	7/20/2016 12:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			883747300	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			MN	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			016057	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			AZ	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			95094306	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			CO	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			90932700	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			FL	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			612061	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			HI	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			100040030	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			IN	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			0914713	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			IA	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			100396970	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			KS	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			1409235	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			LA	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			4719555	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			MI	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			00939027	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			MS	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			82539367	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			NM	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			100692650	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			OK	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			5525040	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			SD	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			3114600	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			WA	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			80583100	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			WI	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			109288000	6/24/2016 12:23 PM
Medicaid Billing	Medicaid: State	Insert			WY	6/24/2016 12:23 PM
Dates	Participating Approval Date	Update			4/21/2016 12:00:00 AM	4/21/2016 3:12 PM
Details	State	Update		Pending	Active	4/21/2016 3:12 PM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	4/21/2016 3:12 PM
Details	340B ID	Update		DSH240036-17	DSH240036R	4/8/2016 12:58 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_58948	DSH240036-17	4/8/2016 11:17 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_58948	4/4/2016 8:46 PM
Details	Last Recertification Date	Insert				4/4/2016 8:46 PM
Details	Grant Number	Insert				4/4/2016 8:46 PM
Details	340B ID	Insert				4/4/2016 8:46 PM
Details	Is Authorizing Official EHB Data	Insert				4/4/2016 8:46 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/4/2016 8:46 PM
Details	Medicare Provider Number	Insert			240036	4/4/2016 8:46 PM
Details	Entity Name	Insert			ST. CLOUD HOSPITAL	4/4/2016 8:46 PM
Details	Program Code	Insert			DSH	4/4/2016 8:46 PM
Details	Entity Subname	Insert			Dialysis - Saint Cloud	4/4/2016 8:46 PM
Dates	Participating Approval Date	Insert				4/4/2016 8:46 PM
Details	State	Insert			Pending	4/4/2016 8:46 PM
Dates	Registration Date	Insert			4/4/2016 12:00:00 AM	4/4/2016 8:46 PM
Dates	Signed By Date	Insert			4/4/2016 12:00:00 AM	4/4/2016 8:46 PM
Dates	Start Date	Insert				4/4/2016 8:46 PM
Terminations	Termination Comments	Insert				4/4/2016 8:46 PM
Terminations	Termination Date	Insert				4/4/2016 8:46 PM
Terminations	Termination Effective Date	Insert				4/4/2016 8:46 PM
Terminations	Termination Reason	Insert				4/4/2016 8:46 PM