Covered Entity Details

CAH241336-00 KITTSON MEMORIAL HOSPITAL (Active) - information as of 5/23/2025 12:00:10 AM

Main Details

Name

KITTSON MEMORIAL HOSPITAL

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH241336-00

Medicare Provider Number

241336

Additional Details

Current Program Status

Active

Registration Date

1/6/2017

Participating Start Date

4/1/2017

Participating Approval Date

1/13/2017

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Kittson Memorial Hospital
Andrea Jane Swenson, CEO
(218) 843-3612

Primary Contact

Kittson Memorial Hospital Assn
Nicole Johnson, Hospital Pharmacist
(218) 843-3612 Ext: 152

Addresses

Street Address

1010 S BIRCH AVE
HALLOCK, MN 56728

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?
No

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	HEALTHY PHARMACY CO.	DBA KITTSON PHARMACY	1010 S BIRCH AVE	HALLOCK	MN	56728	01/17/2023	01/17/2023	04/01/2025	04/01/2025
Contract Detail	KITTSON PHARMACY	1010 S BIRCH AVE		HALLOCK	MN	56728	10/14/2022	01/01/2023	01/17/2023	01/18/2023
Contract Detail	THRIFTY WHITE DRUG #756	101 CLEVELAND AVE E	P.O. BOX 197	KARLSTAD	MN	56732-4512	07/11/2019	10/01/2019		10/01/2019
Contract Detail	THRIFTY WHITE PARTNERS IN CARE	706 38TH ST NW UNIT B		FARGO	ND	58102	10/14/2022	01/01/2023	04/26/2023	05/02/2023
Contract Detail	WHITE DRUG #52	706 38TH ST N STE B		FARGO	ND	58102-2953	07/11/2019	10/01/2019	06/28/2022	07/08/2022
Contract Detail	WHITE DRUG #61	706 38TH ST NW UNIT A		FARGO	ND	58102	07/11/2019	10/01/2019		10/01/2019

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH241336-01	Child	CAH	KITTSON MEMORIAL HOSPITAL	KITTSON MEMORIAL CLINIC - KARLSTAD - Kittson Memorial Clinic - Karlstad	205 Roosevelt Ave	Karlstad	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Delete	Recertification	KITTSON PHARMACY 1010 SOUTH BIRCH AVE HALLOCK, MN 56728		8/13/2024 8:59 AM
Addresses	Main Address	Update	Recertification	1010 SOUTH BIRCH AVE HALLOCK, MN 56728	1010 S BIRCH AVE HALLOCK, MN 56728	8/13/2024 8:59 AM
Details	Last Recertification Date	Update	Recertification	8/24/2023 10:22:41 AM	8/13/2024 8:59:04 AM	8/13/2024 8:59 AM
Details	Last Recertification Date	Update	Recertification	9/7/2022 4:02:35 PM	8/24/2023 10:22:41 AM	8/24/2023 10:22 AM
Contacts	Authorizing Official	Update	AO Change Request	Butler, Everett CEO Kittson Memorial Hospital 2188433803	Swenson, Andrea Jane CEO Kittson Memorial Hospital 2188433612	4/26/2023 9:53 AM
Contacts	Authorizing Official	Update	AO Change Request	Parnell, Brenda CFO Kittson Memorial 9072293546	Butler, Everett CEO Kittson Memorial Hospital 2188433803	1/10/2023 10:31 AM
Contacts	Authorizing Official	Update	AO Change Request	Schwenzfeier, Jeni Chief Financial Officer Kittson Memorial Hospital Assn 2188433612	Parnell, Brenda CFO Kittson Memorial 9072293546	9/29/2022 2:52 PM
Details	Last Recertification Date	Update	Recertification	8/16/2021 10:08:59 AM	9/7/2022 4:02:35 PM	9/7/2022 4:02 PM
Details	Last Recertification Date	Update	Recertification	8/17/2020 10:20:55 AM	8/16/2021 10:08:59 AM	8/16/2021 10:08 AM
Details	Last Recertification Date	Update	Recertification	8/19/2019 8:48:54 AM	8/17/2020 10:20:55 AM	8/17/2020 10:20 AM
Details	Last Recertification Date	Update	Recertification	8/21/2018 2:37:04 PM	8/19/2019 8:48:54 AM	8/19/2019 8:48 AM
Addresses	Shipping Address	Delete	Change Request	KITTSON PHARMACY 1010 SOUTH BIRCH HALLOCK, MN 56728		6/18/2019 12:16 PM
Addresses	Shipping Address	Insert	Change Request		KITTSON PHARMACY 1010 SOUTH BIRCH AVE HALLOCK, MN 56728	6/18/2019 12:16 PM
Addresses	Main Address	Update	Change Request	1010 SOUTH BIRCH HALLOCK, MN 56728	1010 SOUTH BIRCH AVE HALLOCK, MN 56728	6/18/2019 12:16 PM
Addresses	Shipping Address	Insert	Change Request		KITTSON PHARMACY 1010 SOUTH BIRCH HALLOCK, MN 56728	6/6/2019 11:21 AM
Addresses	Main Address	Update	Change Request	KITTSON PHARMACY 1010 SOUTH BIRCH HALLOCK, MN 56728	1010 SOUTH BIRCH HALLOCK, MN 56728	6/6/2019 11:21 AM
Addresses	Main Address	Update	Change Request	1010 SOUTH BIRCH HALLOCK, MN 56728	KITTSON PHARMACY 1010 SOUTH BIRCH HALLOCK, MN 56728	5/29/2019 10:35 AM
Contacts	Authorizing Official	Update	Change Request	Holt, Derek David CFO Kittson Memorial Healthcare Center 2188433852	Schwenzfeier, Jeni Chief Financial Officer Kittson Memorial Hospital Assn 2188433612	4/17/2019 7:20 AM
Contacts	Primary Contact	Update	Change Request	Johnson, Nicole Hospital Pharmacist Kittson Memorial Hospital Assn 2188433612	Johnson, Nicole Hospital Pharmacist Kittson Memorial Hospital Assn 2188433612-152	4/16/2019 2:17 PM
Contacts	Authorizing Official	Update	AO Change Request	Urbaniak, Cindy CEO Kittson Memorial Healthcare Center 2188433612	Holt, Derek David CFO Kittson Memorial Healthcare Center 2188433852	9/3/2018 7:28 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 12:46:42 PM	8/21/2018 2:37:04 PM	8/21/2018 2:37 PM
Contacts	Primary Contact	Update	Recertification	Urbaniak, Cindy CEO 2188433612	Johnson, Nicole Hospital Pharmacist Kittson Memorial Hospital Assn 2188433612	11/15/2017 12:46 PM
Details	Last Recertification Date	Update	Recertification		11/15/2017 12:46:42 PM	11/15/2017 12:46 PM
Contacts	Authorizing Official	Update		Urbaniak, Cindy CEO 2188433612	Urbaniak, Cindy CEO Kittson Memorial Healthcare Center 2188433612	10/13/2017 4:43 PM
Contacts	Signed By	Update		Urbaniak, Cindy CEO 2188433612	Urbaniak, Cindy CEO Kittson Memorial Healthcare Center 2188433612	10/13/2017 4:43 PM
Addresses	Main Address	Insert			1010 SOUTH BIRCH HALLOCK, MN 56728	1/13/2017 9:29 AM
Contacts	Authorizing Official	Insert			Urbaniak, Cindy CEO 2188433612	1/13/2017 9:29 AM
Contacts	Primary Contact	Insert			Urbaniak, Cindy CEO 2188433612	1/13/2017 9:29 AM
Contacts	Signed By	Insert			Urbaniak, Cindy CEO 2188433612	1/13/2017 9:29 AM
Dates	Participating Approval Date	Update			1/13/2017 12:00:00 AM	1/13/2017 9:28 AM
Details	State	Update		Pending	Active	1/13/2017 9:28 AM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	1/13/2017 9:28 AM
Details	340B ID	Update		ONLINE_REG_74101	CAH241336-00	1/12/2017 3:09 PM
Details	340B ID	Update			ONLINE_REG_74101	1/6/2017 11:09 AM
Details	Last Recertification Date	Insert				1/6/2017 11:09 AM
Details	Grant Number	Insert				1/6/2017 11:09 AM
Details	340B ID	Insert				1/6/2017 11:09 AM
Details	Is Authorizing Official EHB Data	Insert				1/6/2017 11:09 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/6/2017 11:09 AM
Details	Medicare Provider Number	Insert			241336	1/6/2017 11:09 AM
Details	Entity Name	Insert			KITTSON MEMORIAL HOSPITAL	1/6/2017 11:09 AM
Details	Program Code	Insert			CAH	1/6/2017 11:09 AM
Details	Entity Subname	Insert				1/6/2017 11:09 AM
Dates	Participating Approval Date	Insert				1/6/2017 11:09 AM
Details	State	Insert			Pending	1/6/2017 11:09 AM
Dates	Registration Date	Insert			1/6/2017 12:00:00 AM	1/6/2017 11:09 AM
Dates	Signed By Date	Insert			1/6/2017 12:00:00 AM	1/6/2017 11:09 AM
Dates	Start Date	Insert				1/6/2017 11:09 AM
Terminations	Termination Comments	Insert				1/6/2017 11:09 AM
Terminations	Termination Date	Insert				1/6/2017 11:09 AM
Terminations	Termination Effective Date	Insert				1/6/2017 11:09 AM
Terminations	Termination Reason	Insert				1/6/2017 11:09 AM