Covered Entity Details

SCH240075-45 ST JOSEPHS MEDICAL CENTER (Active) - information as of 5/2/2025 10:39:44 PM

Main Details

Name

ST JOSEPHS MEDICAL CENTER

Subdivision Name

Essentia Health St. Joseph's - Brainerd Clinic / Diabetes Center

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH240075-45

Medicare Provider Number

240075

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

2/19/2018

Participating Start Date

4/1/2018

Participating Approval Date

2/22/2018

Last Recertification Date

8/18/2024

Contacts

Authorizing Official

Essentia Health
Bradley Beard, Chief Operating Officer
(218) 786-2652

Primary Contact

Essentia Health
Nick Sharrow, Pharmacy Business Services Director
(218) 606-9246

Addresses

Street Address

2024 S 6TH ST
BRAINERD, MN 56401

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		1568415974,1184866956

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
SCH240075-01	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Pulmonary Disease	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-02	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Cardiology	2024 South Sixth Street	Brainerd	MN	Active
SCH240075-03	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Endocrinology	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-04	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Gastroenterology	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-05	Child	SCH	ST. JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Hemotology/Oncology	2024 South Sixth Street	Brainerd	MN	Terminated
SCH240075-06	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / Family Practice	13060 ISLE DR	BAXTER	MN	Active
SCH240075-07	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Rheumatology	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-08	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Allergy	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-09	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / General Internal Medicine	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-10	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Primary Care Psych	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-11	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Neurology	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-12	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / General Surgery	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-13	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Podiatry	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-14	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / ENT	2024 S 6TH ST	BRAINERD	MN	Terminated
SCH240075-15	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / Urgent Care	13060 ISLE DR	BAXTER	MN	Active
SCH240075-16	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Anticoagulation Management	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-17	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Family Practice	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-18	Child	SCH	ST. JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Travel	2024 South Sixth Street	Brainerd	MN	Terminated
SCH240075-19	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Urology	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-20	Child	SCH	ST. JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pierz Clinic	221 North Main Street	Pierz	MN	Terminated
SCH240075-21	Child	SCH	ST. JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pequot Lakes Clinic	4317 West Woodman Street	Pequot Lakes	MN	Terminated
SCH240075-22	Child	SCH	ST. JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's Pine River Clinic	415 Barclay Avenue	Pine River	MN	Terminated
SCH240075-23	Child	SCH	ST. JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Crosslake Clinic	35205 County Road 3	Crosslake	MN	Terminated
SCH240075-24	Child	SCH	ST. JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pillager Clinic	680 Pillsbury Street North	Pillager	MN	Terminated
SCH240075-25	Child	SCH	ST. JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's- Lakeland Psychiatry Clinic	523 3rd Street North	Brainerd	MN	Terminated
SCH240075-26	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / General Pediatrics	13060 ISLE DR	BAXTER	MN	Active
SCH240075-27	Child	SCH	ST. JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / OB & Gynecology	13060 Isle Drive	Baxter	MN	Terminated
SCH240075-28	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pillager Clinic / Anticoagulation Management	680 PILLSBURY ST N	PILLAGER	MN	Terminated
SCH240075-29	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Nephrology	2024 S 6TH ST	BRAINERD	MN	Terminated
SCH240075-30	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pine River Clinic / Anticoagulation Management	280 BARCLAY AVE W	PINE RIVER	MN	Active
SCH240075-31	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pequot Lakes Clinic / Family Practice	4317 W WOODMAN ST	PEQUOT LAKES	MN	Active
SCH240075-32	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pierz Clinic / Family Practice	138 MAIN ST S	PIERZ	MN	Active
SCH240075-33	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Emily Clinic / Family Practice	20918 COUNTY ROAD 1	EMILY	MN	Active
SCH240075-34	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Pain Management	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-35	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Outpatient Treatment	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-36	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pine River Clinic / Family Practice	280 BARCLAY AVE W	PINE RIVER	MN	Active
SCH240075-37	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Orthopedic Surgery	2024 S 6TH ST	BRAINERD	MN	Terminated
SCH240075-38	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / Outpatient Treatment	13060 ISLE DRIVE	BAXTER	MN	Active
SCH240075-39	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pillager Clinic / Family Practice	680 PILLSBURY ST N	PILLAGER	MN	Active
SCH240075-40	Child	SCH	ST JOSEPHS MEDICAL CENTER	BRAINERD CLINIC - EEG / NEURODIAGNOSTICS	2024 S 6TH ST	Brainerd	MN	Terminated
SCH240075-41	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pequot Lakes Clinic / Anticoagulation Management	4317 W WOODMAN ST	PEQUOT LAKES	MN	Active
SCH240075-42	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Crosslake Clinic / Anticoagulation Management	35205 COUNTY RD 3	CROSSLAKE	MN	Terminated
SCH240075-43	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Audiology	2024 S 6TH ST	BRAINERD	MN	Terminated
SCH240075-44	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Crosslake Clinic / Family Practice	35205 COUNTY RD 3	CROSSLAKE	MN	Active
SCH240075-45	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Diabetes Center	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-46	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / Anticoagulation Management	13060 ISLE DR	BAXTER	MN	Active
SCH240075-47	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pierz Clinic / Anticoagulation Management	138 MAIN ST S	PIERZ	MN	Terminated
SCH240075-48	Child	SCH	ST JOSEPHS MEDICAL CENTER	ESSENTIA HEALTH - ST JOSEPH'S BAXTER - Weight Management	13060 ISLE DRIVE	Baxter	MN	Terminated
SCH240075-49	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / General Internal Medicine	13060 ISLE DR	BAXTER	MN	Active
SCH240075-50	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / Primary Care Psych	13060 ISLE DRIVE	BAXTER	MN	Active
SCH240075-51	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Weight Management	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-52	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / Neurology	13060 ISLE DR	BAXTER	MN	Active
SCH240075-53	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pine River Clinic / Orthopedic Surgery - Essentia Health St. Joseph's - Pine River Clinic / Orthopedic Surgery	280 BARCLAY AVE W	Pine River	MN	Active
SCH240075-54	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pine River Clinic / Urology - Essentia Health St. Joseph's - Pine River Clinic / Urology	280 BARCLAY AVE W	PINE RIVER	MN	Active
SCH240075-55	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Medication Therapy Mgmt - Essentia Health St. Joseph's - Brainerd Clinic / Medication Therapy Mgmt	2024 S SIXTH ST	BRAINERD	MN	Active
SCH240075-56	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / Cardiology - Essentia Health St. Joseph's - Baxter Clinic / Cardiology	13060 ISLE DR	Baxter	MN	Terminated
SCH240075-57	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pine River Clinic / Podiatry - Essentia Health St. Joseph's - Pine River Clinic / Podiatry	280 BARCLAY AVE W	PINE RIVER	MN	Active
SCH240075-58	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Crosslake Clinic / Orthopedic Surgery - Essentia Health St. Joseph's - Crosslake Clinic / Orthopedic Surgery	35205 COUNTY RD 3	CROSSLAKE	MN	Active
SCH240075-59	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pine River Clinic / OB/Gyn - Essentia Health St. Joseph's - Pine River Clinic / OB/Gyn	280 BARCLAY AVE W	PINE RIVER	MN	Active
SCH240075-60	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Palliative Care - Essentia Health St. Joseph's - Brainerd Clinic / Palliative Care	2024 S SIXTH ST	Brainerd	MN	Active
SCH240075-61	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Infectious Disease - Essentia Health St. Joseph's - Brainerd Clinic / Infectious Disease	2024 S SIXTH ST	BRAINERD	MN	Active
SCH240075-62	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pierz Clinic / OBGyn - Essentia Health St. Joseph's - Pierz Clinic / OBGyn	138 MAIN ST S	PIERZ	MN	Active
SCH240075-63	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pine River Clinic / General Surgery - Essentia Health St. Joseph's - Pine River Clinic / General Surgery	280 BARCLAY AVE W	PINE RIVER	MN	Active
SCH240075-64	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pierz Clinic / - Orthopedic Surgery	138 MAIN ST S	PIERZ	MN	Active
SCH240075-65	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pillager Clinic / - Orthopedic Surgery	680 PILLSBURY ST N	PILLAGER	MN	Active
SCH240075-66	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pierz Clinic / - Podiatry	138 MAIN ST S	PIERZ	MN	Active
SCH240075-67	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / - Echocardiography	2024 S SIXTH ST	BRAINERD	MN	Terminated
SCH240075-68	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Crosslake Clinic / - Weight Management - CL	35205 CTY ROAD 3	CROSSLAKE	MN	Active
SCH240075-69	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pequot Lakes Clinic / - Cardiology - BMC	4317 WOODMAN STREET	PEQUOT LAKES	MN	Active
SCH240075-70	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic - General Radiology - BAX	13060 ISLE DRIVE	BAXTER	MN	Active
SCH240075-71	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pierz Clinic / - General Radiology - PRZ	138 MAIN ST S	PIERZ	MN	Active
SCH240075-72	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / - General Radiology - BMC	2024 South 6th Street	BRAINERD	MN	Active
SCH240075-73	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Emily Clinic / - General Radiology - Emily	20918 COUNTY ROAD 1	EMILY	MN	Active
SCH240075-74	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pine River Clinic / - General Radiology - PR	280 BARCLAY AVENUE W	PINE RIVER	MN	Active
SCH240075-75	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Crosslake Clinic / - General Radiology - CL	35205 Cty Road 3	CROSSLAKE	MN	Active
SCH240075-76	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / - Dexascan - BAX	13060 ISLE DRIVE	BAXTER	MN	Active
SCH240075-77	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pillager Clinic / - General Radiology - PLG	680 Pillsbury Street N	PILLAGER	MN	Active
SCH240075-78	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / - Pulmonary Function Lab	2024 SOUTH SIXTH ST	BRAINERD	MN	Active
SCH240075-79	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / - Elder Care - BMC	2024 SOUTH SIXTH ST	BRAINERD	MN	Active
SCH240075-80	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / - Pediatric Pulmonology - BAX	13060 ISLE DRIVE	BAXTER	MN	Active
SCH240075-81	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Baxter Clinic / - Diabetes Center	13060 ISLE DRIVE	BAXTER	MN	Active
SCH240075-82	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St Josephs Deerwood Clinic / - General Surgery - DRWD	24087 CUYUNA ST	DEERWOOD	MN	Active
SCH240075-83	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St Josephs Deerwood Clinic / - Family Practice - DRWD	24087 CUYUNA ST	DEERWOOD	MN	Active
SCH240075-84	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Crosslake Clinic / - General Surgery - BMC	35205 Cty Road 3	CROSSLAKE	MN	Active
SCH240075-85	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Brainerd Clinic / - General Pediatrics - BAX	2024 S 6TH ST	BRAINERD	MN	Active
SCH240075-86	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St Josephs Deerwood Clinic / - Cardiology - DRWD	24066 HIGHWAY 210	DEERWOOD	MN	Active
SCH240075-87	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St Josephs Deerwood Clinic / - Urology - DRWD	24066 HIGHWAY 210	DEERWOOD	MN	Active
SCH240075-88	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St Josephs Deerwood Clinic / - Orthopedic Surgery - DRWD	24066 HWY 210	DEERWOOD	MN	Active
SCH240075-89	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pine River Clinic / - Cardiology - PR	280 BARCLAY AVE W	PINE RIVER	MN	Active
SCH240075-90	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St Josephs-Crosslake Clinic / - Cardiology - CL	35206 CTY ROAD 3	CROSSLAKE	MN	Active
SCH240075-91	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St Josephs Deerwood Clinic / - OB and Gynecology - DRWD	24066 HIGHWAY 210	DEERWOOD	MN	Active
SCH240075-92	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Crosslake Clinic / - Anticoagulation Mgmt - CL	35206 Cty Road 3	CROSSLAKE	MN	Active
SCH240075-93	Child	SCH	ST JOSEPHS MEDICAL CENTER	Essentia Health St. Joseph's - Pierz Clinic / - Cardiology - PRZ	138 MAIN ST S	PIERZ	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 11:04:43 AM	8/18/2024 2:21:09 PM	8/18/2024 2:21 PM
Contacts	Primary Contact	Update	Group Change Request	Brooks-Dockendorf, Rhonda 340B Program Coordinator Essentia Health 2187864423	Sharrow, Nick Pharmacy Business Services Director Essentia Health 2186069246	2/27/2024 9:38 AM
Contacts	Primary Contact	Update	Group Change Request	Sedlachek, Andrea 340B Senior Coordinator Essentia Health 2183936699	Brooks-Dockendorf, Rhonda 340B Program Coordinator Essentia Health 2187864423	11/7/2023 9:07 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 4:00:24 PM	8/29/2023 11:04:43 AM	8/29/2023 11:04 AM
Contacts	Authorizing Official	Update	Change Request	Larson, Michael J Vice President of Operations Essentia Health 2188287656	Beard, Bradley Chief Operating Officer Essentia Health 2187862652	6/22/2023 8:03 AM
Contacts	Primary Contact	Update	PC Change Request	Olivier, Ryan Pharmacy 340B Manager Essentia Health 2185760677	Sedlachek, Andrea 340B Senior Coordinator Essentia Health 2183936699	5/24/2023 9:13 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 1:23:40 PM	8/24/2022 4:00:24 PM	8/24/2022 4:00 PM
Contacts	Primary Contact	Update	Group Change Request	Kaufenberg, Anthony Vice President, Pharmacy Essentia Health 2188287693	Olivier, Ryan Pharmacy 340B Manager Essentia Health 2185760677	9/20/2021 6:25 AM
Details	Last Recertification Date	Update	Recertification	8/24/2020 9:52:32 AM	9/9/2021 1:23:40 PM	9/9/2021 1:23 PM
Contacts	Primary Contact	Update	Group Change Request	Heide, Dawn 340B Senior Program Coordinator Essentia Health 2188287143	Kaufenberg, Anthony Vice President, Pharmacy Essentia Health 2188287693	7/12/2021 7:46 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184866956 (WI)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1568415974 (WI)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184866956 (MI)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1568415974 (MI)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184866956 (ND)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1568415974 (ND)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184866956 (SD)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1568415974 (SD)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184866956 (IA)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1568415974 (IA)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184866956 (IL)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1568415974 (IL)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184866956 (NY)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1568415974 (NY)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184866956 (CA)		4/6/2021 9:32 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1568415974 (CA)		4/6/2021 9:32 AM
Contacts	Primary Contact	Update	Change Request	Lundberg, Bryan 340b Program Manager Essentia Health 2188287143	Heide, Dawn 340B Senior Program Coordinator Essentia Health 2188287143	1/31/2021 12:42 PM
Contacts	Primary Contact	Update	Profile Change Request	Lundberg, Bryan 340b Program Manager Essentia Health 2185760745	Lundberg, Bryan 340b Program Manager Essentia Health 2188287143	10/9/2020 9:19 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1184866956	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1568415974	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1184866956	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1568415974	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1184866956	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		ND	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1568415974	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		ND	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1184866956	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		SD	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1568415974	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		SD	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1184866956	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1568415974	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1184866956	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1568415974	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1184866956	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1568415974	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1184866956	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/24/2020 9:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1568415974	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Update	Recertification		MN	8/24/2020 9:52 AM
Medicaid Billing	NPI: State	Update	Recertification		MN	8/24/2020 9:52 AM
Details	Last Recertification Date	Update	Recertification	8/26/2019 4:20:11 PM	8/24/2020 9:52:32 AM	8/24/2020 9:52 AM
Contacts	Primary Contact	Update	Profile Change Request	Lundberg, Bryan 340b Program Manager Essentia 2185760745	Lundberg, Bryan 340b Program Manager Essentia Health 2185760745	4/1/2020 10:07 AM
Contacts	Authorizing Official	Update	Change Request	Pilot, David CFO Essentia Health 2188287642	Larson, Michael J Vice President of Operations Essentia Health 2188287656	3/31/2020 6:27 PM
Details	Entity Subname	Update	Change Request	BRAINERD CLINIC - DIABETES CENTER	Essentia Health St. Joseph's - Brainerd Clinic / Diabetes Center	1/9/2020 8:06 AM
Details	Last Recertification Date	Update	Recertification	9/6/2018 4:25:35 PM	8/26/2019 4:20:11 PM	8/26/2019 4:20 PM
Details	Last Recertification Date	Update	Recertification		9/6/2018 4:25:35 PM	9/6/2018 4:25 PM
Details	State	Update		Approved	Active	4/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Pilot, David CFO Essentia Health 2188287642	2/22/2018 10:25 AM
Details	340B ID	Update	New Registration		SCH240075-45	2/22/2018 10:25 AM
Details	Entity Subname	Update	New Registration	BRAINERD CLINIC	BRAINERD CLINIC - DIABETES CENTER	2/22/2018 10:25 AM
Dates	Participating Approval Date	Update	New Registration		2/22/2018 10:25:58 AM	2/22/2018 10:25 AM
Details	State	Update	New Registration	Pending	Approved	2/22/2018 10:25 AM
Dates	Signed By Date	Update	New Registration		2/19/2018 2:43:57 PM	2/22/2018 10:25 AM
Dates	Start Date	Update	New Registration		4/1/2018 12:00:00 AM	2/22/2018 10:25 AM
Addresses	Main Address	Insert	New Registration		2024 S 6TH ST Brainerd, MN 56401	2/19/2018 10:27 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1568415974	2/19/2018 10:27 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1184866956	2/19/2018 10:27 AM
Contacts	Primary Contact	Insert	New Registration		Lundberg, Bryan 340b Program Manager Essentia 2185760745	2/19/2018 10:27 AM
Contacts	Authorizing Official	Insert	New Registration		Pilot, David CFO Essentia Health 2188287642	2/19/2018 10:27 AM
Details	Last Recertification Date	Insert	New Registration			2/19/2018 10:27 AM
Details	Grant Number	Insert	New Registration			2/19/2018 10:27 AM
Details	340B ID	Insert	New Registration			2/19/2018 10:27 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			2/19/2018 10:27 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			2/19/2018 10:27 AM
Details	Medicare Provider Number	Insert	New Registration		240075	2/19/2018 10:27 AM
Details	Entity Name	Insert	New Registration		ST. JOSEPHS MEDICAL CENTER	2/19/2018 10:27 AM
Details	Program Code	Insert	New Registration		SCH	2/19/2018 10:27 AM
Details	Entity Subname	Insert	New Registration		BRAINERD CLINIC	2/19/2018 10:27 AM
Dates	Participating Approval Date	Insert	New Registration			2/19/2018 10:27 AM
Details	State	Insert	New Registration		Pending	2/19/2018 10:27 AM
Dates	Registration Date	Insert	New Registration		2/19/2018 10:27:45 AM	2/19/2018 10:27 AM
Dates	Signed By Date	Insert	New Registration			2/19/2018 10:27 AM
Dates	Start Date	Insert	New Registration			2/19/2018 10:27 AM
Terminations	Termination Comments	Insert	New Registration			2/19/2018 10:27 AM
Terminations	Termination Date	Insert	New Registration			2/19/2018 10:27 AM
Terminations	Termination Effective Date	Insert	New Registration			2/19/2018 10:27 AM
Terminations	Termination Reason	Insert	New Registration			2/19/2018 10:27 AM