Covered Entity Details

CAH521329-76 ST MARYS HOSPITAL OF SUPERIOR (Active) - information as of 5/27/2025 11:42:48 PM

Main Details

Name

ST MARYS HOSPITAL OF SUPERIOR

Subdivision Name

Essentia Health Hayward Clinic - Radiology - Essentia Health Hayward Clinic - Radiology

Type

Critical Access Hospital

Rural

340B ID

CAH521329-76

Medicare Provider Number

521329

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

5/5/2023

Participating Start Date

7/1/2023

Participating Approval Date

5/22/2023

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

11134 N STATE RD 77
Hayward, WI 54843

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	521329	1083161301,1083657886,1528518883,1588691588
WI	521329	1083161301,1083657886,1528518883,1588691588
MI	521329	1083161301,1083657886,1528518883,1588691588

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
CAH521329-01	Child	CAH	ST MARY'S HOSP OF SUPERIOR	ST. MARY'S - SUPERIOR CLINIC	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-02	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Fam/General Practice Sup	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-03	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Ear, Nose & Throat	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-04	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / General Surgery	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-05	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Psychiatry	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-06	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Gen Internal Med	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-07	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Interventional Pain Ctr	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-08	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Rheumatology Osteo	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-09	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Endoscopy 1st st.	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-10	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Diabetes Center	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-11	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Med Ortho	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-12	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Surgery Ortho	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-13	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Pain Management	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-14	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Emergency Services	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-15	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Urology	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-16	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Opthalmology	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-17	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / OB/GYN	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-18	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Podiatry	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-19	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Vascular Surgery	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-20	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / General Surgery	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-21	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Occupational Medicine	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-22	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Nephrology	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-23	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Infectious Disease	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-24	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Gastrenterology	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-25	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Cardiology	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-26	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Pulmonary Disease	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-27	Child	CAH	ST MARYS HOSPITAL SUPERIOR	SUPERIOR CLINIC / Rheumatology	3500 TOWER AVENUE	SUPERIOR	WI	Terminated
CAH521329-28	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Ambulatory Infusion	1180 Chandler Drive	Spooner	WI	Terminated
CAH521329-29	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Pulmonary Disease	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-30	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Rheumatology	1180 CHANDLER DR	SPOONER	WI	Active
CAH521329-31	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Cardiology	1180 CHANDLER DR	SPOONER	WI	Active
CAH521329-32	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Neurology	1180 CHANDLER DR	SPOONER	WI	Terminated
CAH521329-33	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Hematology / Oncology	1180 CHANDLER DR	SPOONER	WI	Active
CAH521329-34	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Family Practice	1180 CHANDLER DR	SPOONER	WI	Active
CAH521329-35	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Orthopedic Medicine	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-36	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Gastroenterology	1180 CHANDLER DR	SPOONER	WI	Active
CAH521329-37	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Nephrology	1180 CHANDLER DR	SPOONER	WI	Active
CAH521329-38	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Ear, Nose & Throat	1180 CHANDLER DR	SPOONER	WI	Terminated
CAH521329-39	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Anticoagulation Mgmt	1180 CHANDLER DR	SPOONER	WI	Terminated
CAH521329-40	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Neurodiagnostics / EEG	1180 CHANDLER DR	SPOONER	WI	Terminated
CAH521329-41	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Audiology	1180 Chandler Drive	Spooner	WI	Terminated
CAH521329-42	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Endocrinology	1180 CHANDLER DR	SPOONER	WI	Terminated
CAH521329-43	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Pulmonary Disease	1180 CHANDLER DR	SPOONER	WI	Active
CAH521329-44	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - General Pediatrics	1180 Chandler Drive	Spooner	WI	Active
CAH521329-45	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Ambulatory Infusion	11134 N State Road 77	Hayward	WI	Terminated
CAH521329-46	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Sleep Medicine	1180 CHANDLER DR	SPOONER	WI	Active
CAH521329-47	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - OB & Gynecology	1180 CHANDLER DR	SPOONER	WI	Terminated
CAH521329-48	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Physical Medicine & Rehab	1180 CHANDLER DR	SPOONER	WI	Terminated
CAH521329-49	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Orthopedic Surgery	1180 CHANDLER DR	SPOONER	WI	Active
CAH521329-50	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Non Invasive	1180 CHANDLER DR	SPOONER	WI	Active
CAH521329-51	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Pacemaker Clinic	1180 Chandler Drive	Spooner	WI	Active
CAH521329-52	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Physical Medicine & Rehab	11134 N STATE RD 77	HAYWARD	WI	Terminated
CAH521329-53	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Non Invasive	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-54	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Ear, Nose & Throat	11134 N STATE RD 77	HAYWARD	WI	Terminated
CAH521329-55	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Pacemaker Clinic	11134 N State Road 77	Hayward	WI	Active
CAH521329-56	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Audiology	11134 N State Road 77	Hayward	WI	Terminated
CAH521329-57	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Cardiology	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-58	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Urology	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-59	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Hematology / Oncology	11134 N STATE RD 77	HAYWARD	WI	Terminated
CAH521329-60	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Anticoagulation Mgmt	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-61	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Family Practice	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-62	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Nephrology	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-63	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Physical Therapy	11134 N State Road 77	Hayward	WI	Terminated
CAH521329-64	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Sleep Medicine	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-65	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - General Surgery	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-66	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Rheumatology	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-67	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Orthopedic Surgery	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-68	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Endocrinology	11134 N STATE RD 77	HAYWARD	WI	Terminated
CAH521329-69	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Vascular Surgery	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-70	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Podiatry	11134 N STATE RD 77	HAYWARD	WI	Active
CAH521329-71	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Pain Managment	11134 N STATE RD 77	HAYWARD	WI	Terminated
CAH521329-72	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Pain Management	1180 CHANDLER DRIVE	SPOONER	WI	Active
CAH521329-73	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Medication Therapy Management - Essentia Health Hayward Clinic - Medication Therapy Management	11134 N STATE RD 77	Hayward	WI	Active
CAH521329-74	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Diabetes Center - Essentia Health Hayward Clinic - Diabetes Center	11134 N STATE RD 77	Hayward	WI	Terminated
CAH521329-75	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Medication Therapy Management - Essentia Health Spooner Clinic - Medication Therapy Management	1180 CHANDLER DR	Spooner	WI	Active
CAH521329-76	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - Radiology - Essentia Health Hayward Clinic - Radiology	11134 N STATE RD 77	Hayward	WI	Active
CAH521329-77	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Hayward Clinic - General Radiology - Essentia Health Hayward Clinic - General Radiology	11134 N STATE RD 77	Hayward	WI	Active
CAH521329-78	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic - Podiatry - Essentia Health Spooner Clinic - Podiatry	1180 CHANDLER DR	Spooner	WI	Active
CAH521329-79	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic / - Psychiatry - SPNR	1180 CHANDLER DR	SPOONER	WI	Active
CAH521329-80	Child	CAH	ST MARYS HOSPITAL OF SUPERIOR	Essentia Health Spooner Clinic / - Echocardiography	1180 CHANDLER DR	SPOONER	WI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 10:39:04 AM	8/18/2024 3:08:26 PM	8/18/2024 3:08 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 9:37 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 9:06 AM
Details	Last Recertification Date	Update	Recertification		8/29/2023 10:39:04 AM	8/29/2023 10:39 AM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Contacts	Authorizing Official	Update	Change Request	Pearson, Kim Administrator Essentia Health 7158177017	Beard, Bradley Chief Operating Officer Essentia Health 2187862652	6/26/2023 4:30 PM
Contacts	Primary Contact	Update	PC Change Request	Olivier, Ryan Pharmacy 340B Manager Essentia Health 2185760677	Sedlachek, Andrea 340B Senior Coordinator Essentia Health 2183936699	5/25/2023 8:12 AM
Contacts	Signed By	Insert	New Registration		Pearson, Kim Administrator Essentia Health 7158177017	5/22/2023 8:06 AM
Details	340B ID	Update	New Registration		CAH521329-76	5/22/2023 8:06 AM
Details	Entity Name	Update	New Registration	ST MARYS HOSPITAL SUPERIOR	ST MARYS HOSPITAL OF SUPERIOR	5/22/2023 8:06 AM
Details	Entity Subname	Update	New Registration	Essentia Health Hayward Clinic - Radiology	Essentia Health Hayward Clinic - Radiology - Essentia Health Hayward Clinic - Radiology	5/22/2023 8:06 AM
Dates	Participating Approval Date	Update	New Registration		5/22/2023 8:06:08 AM	5/22/2023 8:06 AM
Details	State	Update	New Registration	Pending	Approved	5/22/2023 8:06 AM
Dates	Signed By Date	Update	New Registration		5/13/2023 12:31:00 PM	5/22/2023 8:06 AM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	5/22/2023 8:06 AM
Addresses	Main Address	Insert	New Registration		11134 N STATE RD 77 Hayward, WI 54843	5/5/2023 6:43 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	5/5/2023 6:43 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		521329	5/5/2023 6:43 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	5/5/2023 6:43 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	5/5/2023 6:43 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		521329	5/5/2023 6:43 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	5/5/2023 6:43 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	5/5/2023 6:43 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		521329	5/5/2023 6:43 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083161301	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		MN	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083657886	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		MN	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1528518883	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		MN	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1588691588	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		MN	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083161301	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083657886	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1528518883	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1588691588	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083161301	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		MI	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083657886	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		MI	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1528518883	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		MI	5/5/2023 6:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1588691588	5/5/2023 6:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		MI	5/5/2023 6:43 AM
Contacts	Authorizing Official	Insert	New Registration		Pearson, Kim Administrator Essentia Health 7158177017	5/5/2023 6:43 AM
Contacts	Primary Contact	Insert	New Registration		Olivier, Ryan Pharmacy 340B Manager Essentia Health 2185760677	5/5/2023 6:43 AM
Details	Assistance Received From Date	Insert	New Registration			5/5/2023 6:43 AM
Details	Assistance Received To Date	Insert	New Registration			5/5/2023 6:43 AM
Details	Last Recertification Date	Insert	New Registration			5/5/2023 6:43 AM
Details	Grant Number	Insert	New Registration			5/5/2023 6:43 AM
Details	340B ID	Insert	New Registration			5/5/2023 6:43 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			5/5/2023 6:43 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			5/5/2023 6:43 AM
Details	Medicare Provider Number	Insert	New Registration		521329	5/5/2023 6:43 AM
Details	Entity Name	Insert	New Registration		ST MARYS HOSPITAL SUPERIOR	5/5/2023 6:43 AM
Details	NOFO Number	Insert	New Registration			5/5/2023 6:43 AM
Details	Program Code	Insert	New Registration		CAH	5/5/2023 6:43 AM
Details	Entity Subname	Insert	New Registration		Essentia Health Hayward Clinic - Radiology	5/5/2023 6:43 AM
Dates	Participating Approval Date	Insert	New Registration			5/5/2023 6:43 AM
Details	State	Insert	New Registration		Pending	5/5/2023 6:43 AM
Dates	Registration Date	Insert	New Registration		5/5/2023 6:43:22 AM	5/5/2023 6:43 AM
Dates	Signed By Date	Insert	New Registration			5/5/2023 6:43 AM
Dates	Start Date	Insert	New Registration			5/5/2023 6:43 AM
Terminations	Termination Comments	Insert	New Registration			5/5/2023 6:43 AM
Terminations	Termination Date	Insert	New Registration			5/5/2023 6:43 AM
Terminations	Termination Effective Date	Insert	New Registration			5/5/2023 6:43 AM
Terminations	Termination Reason	Insert	New Registration			5/5/2023 6:43 AM