Covered Entity Details

DSH240196 PHILLIPS EYE INSTITUTE (Terminated) - information as of 6/2/2025 8:28:52 AM

Main Details

Name

PHILLIPS EYE INSTITUTE

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240196

Medicare Provider Number

240196

Additional Details

Current Program Status

Terminated

Registration Date

7/6/2017

Participating Start Date

10/1/2017

Participating Approval Date

7/20/2017

Last Recertification Date

11/9/2017

Termination Date
Termination Reason

7/1/2018
DSH percentage below statutory minimum

Contacts

Authorizing Official

Allina Health
Daniel Conrad, President, Phillips Eye Institute
(612) 775-8815

Primary Contact

Allina
Julie Exner, Financial Analyst, Phillips Eye Institute
(612) 775-8791

Addresses

Street Address

2215 PARK AVENUE
MINNEAPOLIS, MN 55404

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	240196
ND	240196
SD	240196
IA	240196
WI	240196
		1457319527

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 PHILLIPS EYE INSTITUTE PHA	2215 PARK AVE SOUTH		MINNEAPOLIS	MN	55404	10/16/2017	01/01/2018		07/01/2018	07/01/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
No records to display.

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Delete		1457319527 ( )		8/31/2024 9:59 AM
Medicaid Billing	NPI: Number	Delete		1457319527 ( )		8/31/2024 9:59 AM
Medicaid Billing	NPI: Number	Delete		1457319527 ( )		8/31/2024 9:59 AM
Medicaid Billing	NPI: Number	Delete		1457319527 ( )		8/31/2024 9:59 AM
Details	State	Update		To Be Terminated	Terminated	7/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/31/2018 12:00:00 AM	6/14/2018 1:17 PM
Details	State	Update	Termination Request	Active	To Be Terminated	6/14/2018 1:17 PM
Terminations	Termination Date	Update	Termination Request		7/1/2018 12:00:00 AM	6/14/2018 1:17 PM
Terminations	Termination Effective Date	Update	Termination Request		6/1/2018 12:00:00 AM	6/14/2018 1:17 PM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	6/14/2018 1:17 PM
Details	Last Recertification Date	Update	Recertification	10/24/2017 3:27:10 PM	11/9/2017 5:10:09 PM	11/9/2017 5:10 PM
Details	Last Recertification Date	Update	Recertification		10/24/2017 3:27:10 PM	10/24/2017 3:27 PM
Contacts	Authorizing Official	Update		Conrad, Daniel President, Phillips Eye Institute 6127758815	Conrad, Daniel President, Phillips Eye Institute Allina Health 6127758815	10/16/2017 2:43 PM
Contacts	Signed By	Update		Conrad, Daniel President, Phillips Eye Institute 6127758815	Conrad, Daniel President, Phillips Eye Institute Allina Health 6127758815	10/16/2017 2:43 PM
Contacts	Primary Contact	Update		Exner, Julie Financial Analyst, Phillips Eye Institute 6127758791	Exner, Julie Financial Analyst, Phillips Eye Institute Allina 6127758791	10/10/2017 4:02 PM
Addresses	Main Address	Insert			2215 PARK AVENUE MINNEAPOLIS, MN 55404	7/20/2017 3:15 PM
Contacts	Primary Contact	Insert			Exner, Julie Financial Analyst, Phillips Eye Institute 6127758791	7/20/2017 3:15 PM
Contacts	Authorizing Official	Insert			Conrad, Daniel President, Phillips Eye Institute 6127758815	7/20/2017 3:15 PM
Contacts	Signed By	Insert			Conrad, Daniel President, Phillips Eye Institute 6127758815	7/20/2017 3:15 PM
Details	State	Update		Approved	Active	7/20/2017 3:15 PM
Dates	Participating Approval Date	Update			7/20/2017 12:00:00 AM	7/20/2017 3:15 PM
Details	State	Update		Pending	Approved	7/20/2017 3:15 PM
Dates	Start Date	Update			10/1/2017 12:00:00 AM	7/20/2017 3:15 PM
Details	340B ID	Update		ONLINE_REG_77872	DSH240196	7/18/2017 7:08 AM
Details	340B ID	Update			ONLINE_REG_77872	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: Number	Insert			240196	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: State	Insert			MN	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: Number	Insert			240196	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: State	Insert			ND	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: Number	Insert			240196	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: State	Insert			SD	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: Number	Insert			240196	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: State	Insert			IA	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: Number	Insert			240196	7/6/2017 1:28 PM
Medicaid Billing	Medicaid: State	Insert			WI	7/6/2017 1:28 PM
Medicaid Billing	NPI: Number	Insert			1457319527	7/6/2017 1:28 PM
Medicaid Billing	NPI: Number	Insert			1457319527	7/6/2017 1:28 PM
Medicaid Billing	NPI: Number	Insert			1457319527	7/6/2017 1:28 PM
Medicaid Billing	NPI: Number	Insert			1457319527	7/6/2017 1:28 PM
Medicaid Billing	NPI: Number	Insert			1457319527	7/6/2017 1:28 PM
Details	Last Recertification Date	Insert				7/6/2017 1:28 PM
Details	Grant Number	Insert				7/6/2017 1:28 PM
Details	340B ID	Insert				7/6/2017 1:28 PM
Details	Is Authorizing Official EHB Data	Insert				7/6/2017 1:28 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/6/2017 1:28 PM
Details	Medicare Provider Number	Insert			240196	7/6/2017 1:28 PM
Details	Entity Name	Insert			PHILLIPS EYE INSTITUTE	7/6/2017 1:28 PM
Details	Program Code	Insert			DSH	7/6/2017 1:28 PM
Details	Entity Subname	Insert				7/6/2017 1:28 PM
Dates	Participating Approval Date	Insert				7/6/2017 1:28 PM
Details	State	Insert			Pending	7/6/2017 1:28 PM
Dates	Registration Date	Insert			7/6/2017 12:00:00 AM	7/6/2017 1:28 PM
Dates	Signed By Date	Insert			7/6/2017 12:00:00 AM	7/6/2017 1:28 PM
Dates	Start Date	Insert				7/6/2017 1:28 PM
Terminations	Termination Comments	Insert				7/6/2017 1:28 PM
Terminations	Termination Date	Insert				7/6/2017 1:28 PM
Terminations	Termination Effective Date	Insert				7/6/2017 1:28 PM
Terminations	Termination Reason	Insert				7/6/2017 1:28 PM