Covered Entity Details

DSH240036AX ST. CLOUD HOSPITAL (Active) - information as of 4/29/2025 1:38:09 AM

Main Details

Name

ST. CLOUD HOSPITAL

Subdivision Name

Saint Cloud Hospital Plaza Gastroenterology - Gastroenterology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH240036AX

Medicare Provider Number

240036

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/13/2021

Participating Start Date

4/1/2021

Participating Approval Date

1/14/2021

Last Recertification Date

8/27/2024

Contacts

Authorizing Official

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

Primary Contact

St. Cloud Hospital
James Mahowald, Senior Director, Pharmacy Services
(320) 251-2700 Ext: 54084

Addresses

Street Address

1900 CentraCare Circle
Suite 2400
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	1043269798	1043269798

Shipping Addresses

Shipping Address 1

Saint Cloud Hospital Infusion Pharmacy
1900 CentraCare Circle
Suite 1600
Saint Cloud, MN 56303

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
Contacts	Primary Contact	Update	Recertification	Buckley, Tegan J Senior Director Pharmacy Services CentraCare 3202512700-76336	Mahowald, James Senior Director, Pharmacy Services St. Cloud Hospital 3202512700-54084	8/27/2024 2:41 PM
Details	Last Recertification Date	Update	Recertification	8/28/2023 10:29:22 AM	8/27/2024 2:41:53 PM	8/27/2024 2:41 PM
Addresses	Billing Address	Insert	Change Request		Saint Cloud Hospital 1406 Sixth Avenue North Saint Cloud, MN 56303	4/12/2024 12:51 PM
Addresses	Shipping Address	Insert	Change Request		Saint Cloud Hospital Infusion Pharmacy 1900 CentraCare Circle Suite 1600 Saint Cloud, MN 56303	4/12/2024 12:51 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 8:44:05 AM	8/28/2023 10:29:22 AM	8/28/2023 10:29 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 9:38:19 AM	8/30/2022 8:44:05 AM	8/30/2022 8:44 AM
Contacts	Primary Contact	Update	PC Change Request	Phipps, Mary Senior Director Pharmacy St Cloud Hospital 3202512700-71287	Buckley, Tegan J Senior Director Pharmacy Services CentraCare 3202512700-76336	6/22/2022 8:11 AM
Details	Last Recertification Date	Update	Recertification		8/16/2021 9:38:19 AM	8/16/2021 9:38 AM
Details	State	Update		Approved	Active	4/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Blair, Michael Allan Chief Financial Officer CentraCare 3202555665	1/14/2021 12:44 PM
Details	340B ID	Update	New Registration		DSH240036AX	1/14/2021 12:44 PM
Details	Entity Subname	Update	New Registration	Saint Cloud Hospital Plaza Gastroenterology	Saint Cloud Hospital Plaza Gastroenterology - Gastroenterology	1/14/2021 12:44 PM
Dates	Participating Approval Date	Update	New Registration		1/14/2021 12:44:27 PM	1/14/2021 12:44 PM
Details	State	Update	New Registration	Pending	Approved	1/14/2021 12:44 PM
Dates	Signed By Date	Update	New Registration		1/13/2021 5:52:00 PM	1/14/2021 12:44 PM
Dates	Start Date	Update	New Registration		4/1/2021 12:00:00 AM	1/14/2021 12:44 PM
Addresses	Main Address	Insert	New Registration		1900 CentraCare Circle Suite 2400 Saint Cloud, MN 56303	1/13/2021 9:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2021 9:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1043269798	1/13/2021 9:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	1/13/2021 9:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043269798	1/13/2021 9:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		MN	1/13/2021 9:06 AM
Contacts	Primary Contact	Insert	New Registration		Phipps, Mary Senior Director Pharmacy St Cloud Hospital 3202512700-71287	1/13/2021 9:06 AM
Contacts	Authorizing Official	Insert	New Registration		Blair, Michael Allan Chief Financial Officer CentraCare 3202555665	1/13/2021 9:06 AM
Details	Assistance Received From Date	Insert	New Registration			1/13/2021 9:06 AM
Details	Assistance Received To Date	Insert	New Registration			1/13/2021 9:06 AM
Details	Last Recertification Date	Insert	New Registration			1/13/2021 9:06 AM
Details	Grant Number	Insert	New Registration			1/13/2021 9:06 AM
Details	340B ID	Insert	New Registration			1/13/2021 9:06 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/13/2021 9:06 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/13/2021 9:06 AM
Details	Medicare Provider Number	Insert	New Registration		240036	1/13/2021 9:06 AM
Details	Entity Name	Insert	New Registration		ST. CLOUD HOSPITAL	1/13/2021 9:06 AM
Details	NOFO Number	Insert	New Registration			1/13/2021 9:06 AM
Details	Program Code	Insert	New Registration		DSH	1/13/2021 9:06 AM
Details	Entity Subname	Insert	New Registration		Saint Cloud Hospital Plaza Gastroenterology	1/13/2021 9:06 AM
Dates	Participating Approval Date	Insert	New Registration			1/13/2021 9:06 AM
Details	State	Insert	New Registration		Pending	1/13/2021 9:06 AM
Dates	Registration Date	Insert	New Registration		1/13/2021 9:06:35 AM	1/13/2021 9:06 AM
Dates	Signed By Date	Insert	New Registration			1/13/2021 9:06 AM
Dates	Start Date	Insert	New Registration			1/13/2021 9:06 AM
Terminations	Termination Comments	Insert	New Registration			1/13/2021 9:06 AM
Terminations	Termination Date	Insert	New Registration			1/13/2021 9:06 AM
Terminations	Termination Effective Date	Insert	New Registration			1/13/2021 9:06 AM
Terminations	Termination Reason	Insert	New Registration			1/13/2021 9:06 AM