Covered Entity Details

DSH240115AA MERCY HOSPITAL (Active) - information as of 6/9/2025 12:01:57 AM

Main Details

Name

MERCY HOSPITAL

Subdivision Name

Mercy Hospital, Unity Campus - CKRI Rehab - Acute Therapy

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240115AA

Medicare Provider Number

240115

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/7/2022

Participating Start Date

10/1/2022

Participating Approval Date

8/9/2022

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Allina Health
Tony M Collins-Kwong, Director, Strategic Sourcing and Services, Pharmacy Services
(612) 262-4785

Primary Contact

Allina Health
Jeremy Enger, 340B Program Manager
(612) 760-7836

Addresses

Street Address

550 Osborne Rd NE
Fridley, MN 55432

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	694245800,247113100,257113100,774468100,928145300,043103000,490057800,995318300,447648200,266650300,624345210,176618101,694245802	1316904287,1447527767,1033426960,1285692145,1699732586,1609056100,1316901333,1700840097,1295799518,1780648964,1598822686,1760446124,1942264270,1780094698,1063449213,1699739045,1851355135,1104880384,1982641346
WI	694245800,247113100,257113100,774468100,928145300,043103000,490057800,995318300,447648200,266650300,624345210,176618101,694245802	1316904287,1447527767,1033426960,1285692145,1699732586,1609056100

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	Last Updated On
Contract Detail	ALLINA HEALTH APPLE VALLEY PHARMACY	14655 GALAXIE AVE		APPLE VALLEY	MN	55124-8602	03/28/2024	04/01/2024	04/01/2024	04/01/2024
Contract Detail	ALLINA HEALTH CAMBRIDGE PHARMACY	701 DELLWOOD ST S		CAMBRIDGE	MN	55008-1920	12/02/2023	01/01/2024	01/01/2024	01/01/2024
Contract Detail	ALLINA HEALTH COTTAGE GROVE PHARMACY	8611 W POINT DOUGLAS RD S		COTTAGE GROVE	MN	55016-4005	03/28/2024	04/01/2024	04/01/2024	04/01/2024
Contract Detail	ALLINA HEALTH FARIBAULT PHARMACY	200 STATE AVE		FARIBAULT	MN	55021	03/28/2024	04/01/2024	04/01/2024	04/01/2024
Contract Detail	ALLINA HEALTH HEART HOSPITAL PHARMACY	920 E 28TH ST STE H1254		MINNEAPOLIS	MN	55407	12/02/2023	01/01/2024	01/01/2024	01/01/2024
Contract Detail	ALLINA HEALTH MERCY PHARMACY	11850 BLACKFOOT ST. NW	STE 190	COON RAPIDS	MN	55433	12/02/2023	01/01/2024	01/01/2024	01/01/2024
Contract Detail	ALLINA HEALTH NEW ULM PHARMACY	1217 8TH ST N STE 1010		NEW ULM	MN	56073-1552	03/28/2024	04/01/2024	04/01/2024	04/01/2024
Contract Detail	ALLINA HEALTH PIPER BUILDING PHARMACY	913 E 26TH ST	1ST FLOOR PIPER BUILDING	MINNEAPOLIS	MN	55404	03/28/2024	04/01/2024	04/01/2024	04/01/2024
Contract Detail	ALLINA HEALTH ST. FRANCIS PHARMACY	1455 SAINT FRANCIS AVE STE 100		SHAKOPEE	MN	55379-3374	03/28/2024	04/01/2024	04/01/2024	04/01/2024
Contract Detail	ALLINA HEALTH UNITED PHARMACY	333 SMITH AVE N		SAINT PAUL	MN	55102-2344	12/02/2023	01/01/2024	01/01/2024	01/01/2024
Contract Detail	ALLINA HEALTH UNITY PHARMACY	550 OSBORNE RD NE		FRIDLEY	MN	55432-2718	12/02/2023	01/01/2024	01/01/2024	01/01/2024
Contract Detail	ALLINA HEALTH WESTHEALTH PHARMACY	2855 CAMPUS DR		PLYMOUTH	MN	55441	12/02/2023	01/01/2024	01/01/2024	01/01/2024
Contract Detail	ALLINA HEALTH WOODBURY PHARMACY	8675 VALLEY CREEK RD		WOODBURY	MN	55125-2337	03/28/2024	04/01/2024	04/01/2024	04/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH240115A	Child	DSH	MERCY HOSPITAL	Minnesota Perinatal Physicians	3960 Coon Rapids Blvd NW	Coon Rapids	MN	Active
DSH240115AA	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus - CKRI Rehab - Acute Therapy	550 Osborne Rd NE	Fridley	MN	Active
DSH240115AB	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus - Apheresis - General Lab	550 Osborne Rd NE	Fridley	MN	Active
DSH240115AC	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus - Cardiac Rehab - Cardiac Rehab	550 Osborne Rd NE	Fridley	MN	Active
DSH240115AD	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus - General Radiology - Radiology	550 Osborne Rd NE	Fridley	MN	Active
DSH240115AE	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus - ICU - Intensive Care	550 Osborne Rd NE	Fridley	MN	Active
DSH240115AF	Child	DSH	MERCY HOSPITAL	Unity 1W Medical Surgical Cardiac - Medical/Surgical	550 Osborne Rd NE	Fridley	MN	Active
DSH240115AG	Child	DSH	MERCY HOSPITAL	Unity 2W Medical Surgical Oncology - Medical/Surgical	550 Osborne Rd NE	Fridley	MN	Active
DSH240115AH	Child	DSH	MERCY HOSPITAL	Unity 3W Medical Surgical Ortho - Medical/Surgical	550 Osborne Rd NE	Fridley	MN	Active
DSH240115B	Child	DSH	MERCY HOSPITAL	Minnesota Perinatal Physicians - Mercy	3776 Coon Rapids Boulevard	Coon Rapids	MN	Terminated
DSH240115C	Child	DSH	MERCY HOSPITAL	Allina Health Cancer Institute - Coon Rapids	11850 Blackfoot Street NW	Coon Rapids	MN	Active
DSH240115D	Child	DSH	MERCY HOSPITAL	Mercy Same Day Surgery Center	11850 Blackfoot Street NW	Coon Rapids	MN	Terminated
DSH240115E	Child	DSH	MERCY HOSPITAL	Courage Kenney Rehabilitation Institute	11850 Blackfoot Street NW	Coon Rapids	MN	Terminated
DSH240115F	Child	DSH	MERCY HOSPITAL	Courage Kenny Kids	3960 Coon Rapids Blvd NW	Coon Rapids	MN	Active
DSH240115G	Child	DSH	MERCY HOSPITAL	Adult Mental Health Outpatient Program	520 Osborne Rd	Fridley	MN	Active
DSH240115H	Child	DSH	MERCY HOSPITAL	Allina Health Mental Health - Mercy Hospital, Unity Campus - Psychiatry, Social Work	520 Osborne Rd	Fridley	MN	Active
DSH240115J	Child	DSH	MERCY HOSPITAL	Virginia Piper Cancer Institute - Mercy Hospital, Unity Campus - Oncology, Surgery	480 Osborne Rd NE	Fridley	MN	Terminated
DSH240115K	Child	DSH	MERCY HOSPITAL	Courage Kenny Rehabilitation Institute - Mercy Hospital, Unity Campus - PT, OT, Lymphedema	480 Osborne Rd NE	Fridley	MN	Terminated
DSH240115L	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus 3 East Imaging - Cardiac Services	550 Osborne Rd NE	Fridley	MN	Active
DSH240115M	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus - Surgical Services	550 Osborne Rd NE	Fridley	MN	Active
DSH240115N	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus CAT Scan - Medical Imaging	550 Osborne Rd NE	Fridley	MN	Active
DSH240115P	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus Special Diagnostics - Medical Imaging	550 Osborne Rd NE	Fridley	MN	Active
DSH240115Q	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus Emergency Services - Emergency Department	550 Osborne Rd NE	Fridley	MN	Active
DSH240115R	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus MRI - Medical Imaging	550 Osborne Rd NE	Fridley	MN	Active
DSH240115S	Child	DSH	MERCY HOSPITAL	Allina Health Outpatient Addiction Services - Mercy Hospital, Unity Campus - Substance Abuse Clinic	520 Osborne Rd	Fridley	MN	Active
DSH240115T	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus Interventional Radiology - Medical Imaging	550 Osborne Rd NE	Fridley	MN	Active
DSH240115U	Child	DSH	MERCY HOSPITAL	Allina Health Addiction Treatment Mercy Hospital, Unity Campus - Adult Addiction Services	550 Osborne Rd NE	Fridley	MN	Active
DSH240115V	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus - Ultrasound - Ultrasound Radiology	550 Osborne Rd NE	Fridley	MN	Active
DSH240115W	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus - ECT - Peri Anesthesia	550 Osborne Rd NE	Fridley	MN	Active
DSH240115X	Child	DSH	MERCY HOSPITAL	Mercy Hospital, Unity Campus - CKRI Rehab - PT	550 Osborne Rd NE	Fridley	MN	Active
DSH240115Y	Child	DSH	MERCY HOSPITAL	Allina Health Cancer Institute - Mercy Hospital, Buffalo Infusion - Infusion	303 Catlin St	Buffalo	MN	Active
DSH240115Z	Child	DSH	MERCY HOSPITAL	Allina Health Cancer Institute - Mercy Hospital, Buffalo Clinic - Infusion	303 Catlin St	Buffalo	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 11:12:02 AM	8/12/2024 5:46:30 PM	8/12/2024 5:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1316901333	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700840097	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1295799518	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1780648964	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1598822686	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760446124	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1942264270	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1780094698	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1063449213	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1699739045	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1851355135	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104880384	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1982641346	6/17/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/17/2024 2:03 PM
Details	Last Recertification Date	Update	Recertification		8/16/2023 11:12:02 AM	8/16/2023 11:12 AM
Details	State	Update		Approved	Active	10/1/2022 12:01 AM
Addresses	Main Address	Insert	New Registration		550 Osborne Rd NE Fridley, MN 55432	8/9/2022 9:57 AM
Contacts	Signed By	Insert	New Registration		Collins-Kwong, Tony M Director, Strategic Sourcing and Services, Pharmacy Services Allina Health 6122624785	8/9/2022 9:57 AM
Details	340B ID	Update	New Registration		DSH240115AA	8/9/2022 9:57 AM
Details	Entity Subname	Update	New Registration	Mercy Hospital, Unity Campus - CKRI Rehab	Mercy Hospital, Unity Campus - CKRI Rehab - Acute Therapy	8/9/2022 9:57 AM
Dates	Participating Approval Date	Update	New Registration		8/9/2022 9:57:40 AM	8/9/2022 9:57 AM
Details	State	Update	New Registration	Pending	Approved	8/9/2022 9:57 AM
Dates	Signed By Date	Update	New Registration		8/4/2022 12:10:07 PM	8/9/2022 9:57 AM
Dates	Start Date	Update	New Registration		10/1/2022 12:00:00 AM	8/9/2022 9:57 AM
Addresses	Main Address	Insert	New Registration		550 Osborne Rd NE Fridley, MN 55432	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		694245800	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		247113100	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		257113100	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		774468100	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		928145300	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		043103000	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		490057800	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		995318300	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		447648200	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		266650300	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		624345210	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		176618101	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		694245802	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		694245800	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		247113100	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		257113100	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		774468100	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		928145300	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		043103000	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		490057800	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		995318300	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		447648200	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		266650300	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		624345210	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		176618101	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		694245802	7/7/2022 4:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316904287	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1447527767	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1033426960	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1285692145	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1699732586	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609056100	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316904287	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1447527767	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1033426960	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1285692145	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1699732586	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609056100	7/7/2022 4:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/7/2022 4:26 PM
Contacts	Authorizing Official	Insert	New Registration		Collins-Kwong, Tony M Director, Strategic Sourcing and Services, Pharmacy Services Allina Health 6122624785	7/7/2022 4:26 PM
Contacts	Primary Contact	Insert	New Registration		Enger, Jeremy 340B Program Manager Allina Health 6127607836	7/7/2022 4:26 PM
Details	Assistance Received From Date	Insert	New Registration			7/7/2022 4:26 PM
Details	Assistance Received To Date	Insert	New Registration			7/7/2022 4:26 PM
Details	Last Recertification Date	Insert	New Registration			7/7/2022 4:26 PM
Details	Grant Number	Insert	New Registration			7/7/2022 4:26 PM
Details	340B ID	Insert	New Registration			7/7/2022 4:26 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/7/2022 4:26 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/7/2022 4:26 PM
Details	Medicare Provider Number	Insert	New Registration		240115	7/7/2022 4:26 PM
Details	Entity Name	Insert	New Registration		MERCY HOSPITAL	7/7/2022 4:26 PM
Details	NOFO Number	Insert	New Registration			7/7/2022 4:26 PM
Details	Program Code	Insert	New Registration		DSH	7/7/2022 4:26 PM
Details	Entity Subname	Insert	New Registration		Mercy Hospital, Unity Campus - CKRI Rehab	7/7/2022 4:26 PM
Dates	Participating Approval Date	Insert	New Registration			7/7/2022 4:26 PM
Details	State	Insert	New Registration		Pending	7/7/2022 4:26 PM
Dates	Registration Date	Insert	New Registration		7/7/2022 4:26:15 PM	7/7/2022 4:26 PM
Dates	Signed By Date	Insert	New Registration			7/7/2022 4:26 PM
Dates	Start Date	Insert	New Registration			7/7/2022 4:26 PM
Terminations	Termination Comments	Insert	New Registration			7/7/2022 4:26 PM
Terminations	Termination Date	Insert	New Registration			7/7/2022 4:26 PM
Terminations	Termination Effective Date	Insert	New Registration			7/7/2022 4:26 PM
Terminations	Termination Reason	Insert	New Registration			7/7/2022 4:26 PM