Covered Entity Details

DSH240022F SANFORD WORTHINGTON MEDICAL CENTER (Active) - information as of 4/29/2025 10:27:47 PM

Main Details

Name

SANFORD WORTHINGTON MEDICAL CENTER

Subdivision Name

Worthington Physical Medicine - Physical Medicine

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH240022F

Medicare Provider Number

240022

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/10/2023

Participating Start Date

7/1/2023

Participating Approval Date

4/11/2023

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Sanford Health
Eric Lucas Vanden Hull, Vice President of Finance - Sioux Falls HSD
(712) 261-5275

Primary Contact

Sanford USD Medical Center
Alyssa O Howard, Director of Pharmacy
(605) 695-1697

Addresses

Street Address

426 10th Street
Worthington, MN 56187

Billing Address

Sanford Worthington Medical Center
1018 6th Avenue
Worthington, MN 56187-0097

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		1396712618,1255598843,1174716245,1912932997,1679859912,1487685970

Shipping Addresses

Shipping Address 1

Sanford Worthington Medical Center
1018 6th Avenue
Worthington, MN 56187-0097

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
DSH240022A	Child	DSH	SANFORD WORTHINGTON MEDICAL CENTER	Sanford Worthington Clinic	1680 Diagonal Rd	Worthington	MN	Active
DSH240022B	Child	DSH	SANFORD WORTHINGTON MEDICAL CENTER	Sanford Worthington Orthopedics and Sports Medicine	1680 Diagonal Road	Worthington	MN	Active
DSH240022C	Child	DSH	SANFORD WORTHINGTON MEDICAL CENTER	Sanford Worthington Pediatrics - Pediatrics	1680 Diagonal Road	Worthington	MN	Active
DSH240022D	Child	DSH	SANFORD WORTHINGTON MEDICAL CENTER	Sanford Worthington Acute Care - Acute Care	1680 Diagonal Road	Worthington	MN	Active
DSH240022E	Child	DSH	SANFORD WORTHINGTON MEDICAL CENTER	Worthington Outreach - Outreach	1680 Diagonal Road	Worthington	MN	Active
DSH240022F	Child	DSH	SANFORD WORTHINGTON MEDICAL CENTER	Worthington Physical Medicine - Physical Medicine	426 10th Street	Worthington	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/5/2023 9:58:33 AM	9/3/2024 3:42:10 PM	9/3/2024 3:42 PM
Addresses	Billing Address	Update	Change Request	Sanford Worthington Medical Center 1018 6th Ave Worthington, MN 56187-0097	Sanford Worthington Medical Center 1018 6th Avenue Worthington, MN 56187-0097	3/11/2024 8:47 AM
Addresses	Shipping Address	Insert	Change Request		Sanford Worthington Medical Center 1018 6th Avenue Worthington, MN 56187-0097	3/11/2024 8:47 AM
Details	Last Recertification Date	Update	Recertification		9/5/2023 9:58:33 AM	9/5/2023 9:58 AM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Vanden Hull, Eric Lucas Vice President of Finance - Sioux Falls HSD Sanford Health 7122615275	4/11/2023 7:37 AM
Details	340B ID	Update	New Registration		DSH240022F	4/11/2023 7:37 AM
Details	Entity Subname	Update	New Registration	Worthington Physical Medicine	Worthington Physical Medicine - Physical Medicine	4/11/2023 7:37 AM
Dates	Participating Approval Date	Update	New Registration		4/11/2023 7:37:29 AM	4/11/2023 7:37 AM
Details	State	Update	New Registration	Pending	Approved	4/11/2023 7:37 AM
Dates	Signed By Date	Update	New Registration		4/10/2023 4:52:13 PM	4/11/2023 7:37 AM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	4/11/2023 7:37 AM
Addresses	Main Address	Insert	New Registration		426 10th Street Worthington, MN 56187	4/10/2023 3:02 PM
Addresses	Billing Address	Insert	New Registration		Sanford Worthington Medical Center 1018 6th Ave Worthington, MN 56187-0097	4/10/2023 3:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1396712618	4/10/2023 3:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/10/2023 3:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1255598843	4/10/2023 3:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/10/2023 3:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1174716245	4/10/2023 3:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/10/2023 3:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1912932997	4/10/2023 3:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/10/2023 3:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1679859912	4/10/2023 3:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/10/2023 3:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1487685970	4/10/2023 3:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/10/2023 3:02 PM
Contacts	Primary Contact	Insert	New Registration		Howard, Alyssa O Director of Pharmacy Sanford USD Medical Center 6056951697	4/10/2023 3:02 PM
Contacts	Authorizing Official	Insert	New Registration		Vanden Hull, Eric Lucas Vice President of Finance - Sioux Falls HSD Sanford Health 7122615275	4/10/2023 3:02 PM
Details	Assistance Received From Date	Insert	New Registration			4/10/2023 3:02 PM
Details	Assistance Received To Date	Insert	New Registration			4/10/2023 3:02 PM
Details	Last Recertification Date	Insert	New Registration			4/10/2023 3:02 PM
Details	Grant Number	Insert	New Registration			4/10/2023 3:02 PM
Details	340B ID	Insert	New Registration			4/10/2023 3:02 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/10/2023 3:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/10/2023 3:02 PM
Details	Medicare Provider Number	Insert	New Registration		240022	4/10/2023 3:02 PM
Details	Entity Name	Insert	New Registration		SANFORD WORTHINGTON MEDICAL CENTER	4/10/2023 3:02 PM
Details	NOFO Number	Insert	New Registration			4/10/2023 3:02 PM
Details	Program Code	Insert	New Registration		DSH	4/10/2023 3:02 PM
Details	Entity Subname	Insert	New Registration		Worthington Physical Medicine	4/10/2023 3:02 PM
Dates	Participating Approval Date	Insert	New Registration			4/10/2023 3:02 PM
Details	State	Insert	New Registration		Pending	4/10/2023 3:02 PM
Dates	Registration Date	Insert	New Registration		4/10/2023 3:02:37 PM	4/10/2023 3:02 PM
Dates	Signed By Date	Insert	New Registration			4/10/2023 3:02 PM
Dates	Start Date	Insert	New Registration			4/10/2023 3:02 PM
Terminations	Termination Comments	Insert	New Registration			4/10/2023 3:02 PM
Terminations	Termination Date	Insert	New Registration			4/10/2023 3:02 PM
Terminations	Termination Effective Date	Insert	New Registration			4/10/2023 3:02 PM
Terminations	Termination Reason	Insert	New Registration			4/10/2023 3:02 PM