Covered Entity Details

CAH241328-05 Sanford Bagley Medical Center (Active) - information as of 6/7/2025 5:56:10 AM

Main Details

Name

Sanford Bagley Medical Center

Subdivision Name

SANFORD BAGLEY CLINIC / Family Medicine

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH241328-05

Medicare Provider Number

241328

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/12/2016

Participating Start Date

7/1/2016

Participating Approval Date

5/3/2016

Last Recertification Date

8/18/2024

Contacts

Authorizing Official

Sanford Health of Northern Minnesota
Lisa Sue Miller, Chief Financial Officer
(218) 333-5523

Primary Contact

Sanford Health of Northern Minnesota
Matthew Aaron Webb, Director of Pharmacy
(218) 333-6339

Addresses

Street Address

1656 CENTRAL W ST
BAGLEY, MN 56621-4357

Billing Address

Sanford Bagley Medical Center
203 4TH ST. NW
BAGLEY, MN 56621

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?
No

Shipping Addresses

Shipping Address 1

Sanford Bagley Medical Center
203 4TH ST. NW
BAGLEY, MN 56621

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
CAH241328-01	Child	CAH	Sanford Bagley Medical Center	SANFORD BAGLEY CLEARBROOK FAMILY MEDICINE CLINIC	22 ELM STREET SW	CLEARBROOK	MN	Active
CAH241328-02	Child	CAH	Sanford Bagley Medical Center	SANFORD BAGLEY CLINIC / Outreach Clinic	1656 CENTRAL W ST	BAGLEY	MN	Active
CAH241328-03	Child	CAH	Sanford Bagley Medical Center	SANFORD BAGLEY CLINIC / Pediatrics	1656 CENTRAL W ST	BAGLEY	MN	Terminated
CAH241328-04	Child	CAH	Sanford Bagley Medical Center	SANFORD BAGLEY CLINIC / Internal Medicine	1656 CENTRAL W ST	BAGLEY	MN	Active
CAH241328-05	Child	CAH	Sanford Bagley Medical Center	SANFORD BAGLEY CLINIC / Family Medicine	1656 CENTRAL W ST	BAGLEY	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/28/2023 10:27:38 AM	8/18/2024 8:39:31 PM	8/18/2024 8:39 PM
Addresses	Billing Address	Insert	Change Request		Sanford Bagley Medical Center 203 4TH ST. NW BAGLEY, MN 56621	6/3/2024 11:08 AM
Contacts	Authorizing Official	Update	Profile Change Request	Miller, Lisa Sue Vice President of Finance Sanford Health of Northern Minnesota 2183335523	Miller, Lisa Sue Chief Financial Officer Sanford Health of Northern Minnesota 2183335523	4/25/2024 9:18 AM
Addresses	Shipping Address	Insert	Change Request		Sanford Bagley Medical Center 203 4TH ST. NW BAGLEY, MN 56621	11/22/2023 7:04 AM
Details	Last Recertification Date	Update	Recertification	9/6/2022 12:38:33 PM	8/28/2023 10:27:38 AM	8/28/2023 10:27 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 3:08:29 PM	9/6/2022 12:38:33 PM	9/6/2022 12:38 PM
Contacts	Primary Contact	Update	Recertification	Eischens, Karla P Director of Pharmacy Sanford Health of Northern Minnesota 2183335543	Webb, Matthew Aaron Director of Pharmacy Sanford Health of Northern Minnesota 2183336339	9/9/2021 3:08 PM
Details	Last Recertification Date	Update	Recertification	8/19/2020 2:07:06 PM	9/9/2021 3:08:29 PM	9/9/2021 3:08 PM
Details	Last Recertification Date	Update	Recertification	8/21/2019 9:43:00 AM	8/19/2020 2:07:06 PM	8/19/2020 2:07 PM
Contacts	Authorizing Official	Update	Change Request	Johnson, Joy Ellen Vice President of Operations Sanford Health of Northern Minnesota 2183336422	Miller, Lisa Sue Vice President of Finance Sanford Health of Northern Minnesota 2183335523	12/13/2019 2:10 PM
Details	Last Recertification Date	Update	Recertification	8/21/2018 4:49:20 PM	8/21/2019 9:43:00 AM	8/21/2019 9:43 AM
Contacts	Authorizing Official	Update	Change Request	BOYER, CRAIG O. Vice President of Finance Sanford Health of Northern Minnesota 2183335508	Johnson, Joy Ellen Vice President of Operations Sanford Health of Northern Minnesota 2183336422	6/7/2019 11:35 AM
Details	Last Recertification Date	Update	Recertification	11/20/2017 9:29:59 AM	8/21/2018 4:49:20 PM	8/21/2018 4:49 PM
Contacts	Primary Contact	Update	Change Request	Bergquist, Barb A. Pharmacist Sanford Bagley Medical Center 2186943939-179	Eischens, Karla P Director of Pharmacy Sanford Health of Northern Minnesota 2183335543	12/27/2017 12:49 PM
Details	Entity Name	Update	Recertification	SANFORD BAGLEY MEDICAL CENTER	Sanford Bagley Medical Center	11/20/2017 9:32 AM
Details	Last Recertification Date	Update	Recertification	8/19/2016 12:00:00 AM	11/20/2017 9:29:59 AM	11/20/2017 9:29 AM
Contacts	Primary Contact	Update	Recertification	Bergquist, Barb Pharmacist 2186943939-179	Bergquist, Barb A. Pharmacist Sanford Bagley Medical Center 2186943939-179	11/20/2017 9:29 AM
Contacts	Authorizing Official	Update	Profile Change Request	BOYER, CRAIG O. CFO Sanford Health of Northern Minnesota 2183335508	BOYER, CRAIG O. Vice President of Finance Sanford Health of Northern Minnesota 2183335508	10/18/2017 1:24 PM
Contacts	Signed By	Update	Profile Change Request	BOYER, CRAIG O. CFO Sanford Health of Northern Minnesota 2183335508	BOYER, CRAIG O. Vice President of Finance Sanford Health of Northern Minnesota 2183335508	10/18/2017 1:24 PM
Contacts	Authorizing Official	Update		BOYER, CRAIG O. CFO 2183335508	BOYER, CRAIG O. CFO Sanford Health of Northern Minnesota 2183335508	10/9/2017 11:03 AM
Contacts	Signed By	Update		BOYER, CRAIG O. CFO 2183335508	BOYER, CRAIG O. CFO Sanford Health of Northern Minnesota 2183335508	10/9/2017 11:03 AM
Contacts	Authorizing Official	Insert			BOYER, CRAIG O. CFO 2183335508	7/26/2017 4:41 PM
Contacts	Signed By	Insert			BOYER, CRAIG O. CFO 2183335508	7/26/2017 4:41 PM
Addresses	Main Address	Insert			1656 CENTRAL W ST BAGLEY, MN 56621-4357	8/19/2016 12:09 PM
Contacts	Primary Contact	Insert			Bergquist, Barb Pharmacist 2186943939-179	8/19/2016 12:09 PM
Details	Last Recertification Date	Update			8/19/2016 12:00:00 AM	8/19/2016 12:09 PM
Dates	Participating Approval Date	Update			5/3/2016 12:00:00 AM	5/3/2016 1:45 PM
Details	State	Update		Pending	Active	5/3/2016 1:45 PM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	5/3/2016 1:45 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_59943	CAH241328-05	4/20/2016 10:18 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_59943	4/12/2016 6:03 PM
Details	Last Recertification Date	Insert				4/12/2016 6:03 PM
Details	Grant Number	Insert				4/12/2016 6:03 PM
Details	340B ID	Insert				4/12/2016 6:03 PM
Details	Is Authorizing Official EHB Data	Insert				4/12/2016 6:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/12/2016 6:03 PM
Details	Medicare Provider Number	Insert			241328	4/12/2016 6:03 PM
Details	Entity Name	Insert			SANFORD BAGLEY MEDICAL CENTER	4/12/2016 6:03 PM
Details	Program Code	Insert			CAH	4/12/2016 6:03 PM
Details	Entity Subname	Insert			SANFORD BAGLEY CLINIC / Family Medicine	4/12/2016 6:03 PM
Dates	Participating Approval Date	Insert				4/12/2016 6:03 PM
Details	State	Insert			Pending	4/12/2016 6:03 PM
Dates	Registration Date	Insert			4/12/2016 12:00:00 AM	4/12/2016 6:03 PM
Dates	Signed By Date	Insert			4/12/2016 12:00:00 AM	4/12/2016 6:03 PM
Dates	Start Date	Insert				4/12/2016 6:03 PM
Terminations	Termination Comments	Insert				4/12/2016 6:03 PM
Terminations	Termination Date	Insert				4/12/2016 6:03 PM
Terminations	Termination Effective Date	Insert				4/12/2016 6:03 PM
Terminations	Termination Reason	Insert				4/12/2016 6:03 PM