Covered Entity Details

DSH240084DT ESSENTIA HEALTH VIRGINIA (Active) - information as of 5/23/2025 12:21:38 AM

Main Details

Name

ESSENTIA HEALTH VIRGINIA

Subdivision Name

Essentia Health Ely Clinic / - Clinic Pharm Withdrawal

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240084DT

Medicare Provider Number

240084

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/1/2023

Participating Start Date

10/1/2023

Participating Approval Date

8/18/2023

Last Recertification Date

8/30/2024

Contacts

Authorizing Official

Essentia Health
Sam Stone, COO
(218) 742-8600 Ext: 2496

Primary Contact

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

Addresses

Street Address

300 W CONAN ST
ELY, MN 55731

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		1326598418,1083617120
WI		1083617120,1326598418

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
DSH240084A	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Medical Arts Clinic / OB & Gynecology - VMAC (Medical Arts Clinic)	901 9th Street North	Virginia	MN	Terminated
DSH240084AA	Child	DSH	ESSENTIA HEALTH VIRGINIA LLC	Essentia Health Virginia Clinic / Integrated Behavioral Health	1101 9th Street North	Virginia	MN	Terminated
DSH240084AB	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Rheumatology Osteo	1101 9th Street North	Virginia	MN	Terminated
DSH240084AC	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Med Ortho	1101 9th Street North	Virginia	MN	Terminated
DSH240084AD	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Surgery Ortho	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084AE	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Pain Management	1101 9TH ST N	VIRGINIA	MN	Terminated
DSH240084AF	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Urology	1101 9th Street North	Virginia	MN	Terminated
DSH240084AG	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Ear, Nose & Throat	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084AH	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Physical Medicine & Rehab	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084AJ	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / OB & Gynecology	1101 9th Street North	Virginia	MN	Terminated
DSH240084AK	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Podiatry	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084AL	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Vascular Surgery	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084AM	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / General Surgery	1101 9th Street North	Virginia	MN	Terminated
DSH240084AN	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Neurology	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084AP	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / General Pediatrics	1101 9th Street North	Virginia	MN	Terminated
DSH240084AQ	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Rheumatology	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084AR	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Pulmonary Disease	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084AS	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Nephrology	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084AT	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Endocrinology	1101 9TH ST N	VIRGINIA	MN	Terminated
DSH240084AU	Child	DSH	ESSENTIA HEALTH VIRGINIA	ESENTIA HEALTH VIRGINIA CLINIC / Vascular Diagnostics - VIR	1101 9TH ST N	VIRGINIA	MN	Terminated
DSH240084AV	Child	DSH	ESSENTIA HEALTH VIRGINIA LLC	ESENTIA HEALTH VIRGINIA CLINIC / Ultrasound - VIR	1101 9TH ST N	VIRGINIA	MN	Terminated
DSH240084AW	Child	DSH	ESSENTIA HEALTH VIRGINIA	ESENTIA HEALTH VIRGINIA CLINIC / Pacemaker Clinic - VIR	1101 9TH ST N	VIRGINIA	MN	Terminated
DSH240084AX	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Hematology/Oncology	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084AY	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Audiology - VIR	1101 9TH ST N	VIRGINIA	MN	Terminated
DSH240084AZ	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Pulmonary Function Lab	1101 9th Street North	Virginia	MN	Active
DSH240084B	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Medical Arts Clinic / Sleep Medicine - Lakewalk	901 9th Street North	Virginia	MN	Terminated
DSH240084BA	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Urology	1101 9th Street North	Virginia	MN	Terminated
DSH240084BB	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Psychiatry	1101 9th Street North	Virginia	MN	Terminated
DSH240084BC	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Orthopedic Medicine	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084BD	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Sleep Medicine	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084BE	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / Nephrology	2501 KEENAN DR	INTERNATIONAL FALLS	MN	Terminated
DSH240084BF	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Ely Clinic / General Internal Medicine	300 W CONAN ST	ELY	MN	Active
DSH240084BG	Child	DSH	ESSENTIA HEALTH VIRGINIA LLC	Essentia Health International Falls Clinic - Anticoagulation Mgmt	2501 Keenan Drive	International Falls	MN	Terminated
DSH240084BH	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Wound Care Center - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084BJ	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Weight Management	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084BK	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / Pulmonary Disease	2501 KEENAN DR	INTERNATIONAL FALLS	MN	Terminated
DSH240084BL	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Dermatology	1101 9TH ST N	VIRGINIA	MN	Terminated
DSH240084BM	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / Physical Medicine & Rehab	2501 KEENAN DR	INTERNATIONAL FALLS	MN	Terminated
DSH240084BN	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Ely Clinic / General Surgery	300 W CONAN ST	ELY	MN	Active
DSH240084BP	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic - Ear, Nose & Throat	2501 Keenan Drive	International Falls	MN	Terminated
DSH240084BQ	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / Psychiatry	2501 KEENAN DR	INTERNATIONAL FALLS	MN	Active
DSH240084BR	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / OB & Gynecology	2501 KEENAN DR	INTERNATIONAL FALLS	MN	Active
DSH240084BS	Child	DSH	ESSENTIA HEALTH VIRGINIA LLC	Essentia Health International Falls Clinic - Endocrinology	2501 Keenan Drive	International Falls	MN	Terminated
DSH240084BT	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / Cardiology	2501 KEENAN DR	INTERNATIONAL FALLS	MN	Active
DSH240084BU	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / Family Practice	2501 KEENAN DR	INTERNATIONAL FALLS	MN	Active
DSH240084BV	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Ely Clinic / Cardiology	300 W CONAN ST	ELY	MN	Active
DSH240084BW	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Ely Clinic / Orthopedic Surgery	300 W CONAN ST	ELY	MN	Active
DSH240084BX	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / Podiatry	2501 KEENAN DR	INTERNATIONAL FALLS	MN	Active
DSH240084BY	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Ely Clinic / Anticoagulation Mgmt	300 W CONAN ST	ELY	MN	Active
DSH240084BZ	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Ely Clinic / OB & Gynecology	300 W CONAN ST	ELY	MN	Terminated
DSH240084C	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Integrated Behav Hlth - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084CA	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Ely Clinic / Family Practice	300 W CONAN ST	ELY	MN	Active
DSH240084CB	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic - Elder Care - VIR	1101 9th Street North	Virginia	MN	Active
DSH240084CC	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Cardiology	730 E 34TH ST	HIBBING	MN	Active
DSH240084CD	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Ambulatory Infusion Center	730 E 34TH ST	HIBBING	MN	Active
DSH240084CE	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Neurology	730 E 34TH ST	HIBBING	MN	Terminated
DSH240084CF	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Orthopedic Medicine	730 E 34TH ST	HIBBING	MN	Active
DSH240084CG	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Nephrology	730 E 34TH ST	HIBBING	MN	Active
DSH240084CH	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Family Practice	730 E 34TH ST	HIBBING	MN	Active
DSH240084CJ	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Physical Therapy	730 E 34TH ST	HIBBING	MN	Active
DSH240084CK	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Weight Management	730 E 34TH ST	HIBBING	MN	Active
DSH240084CL	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Urology	730 E 34TH ST	HIBBING	MN	Active
DSH240084CM	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / General Surgery	2501 KEENAN DR	INTERNATIONAL FALLS	MN	Active
DSH240084CN	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / General Internal Medicine	730 E 34TH ST	HIBBING	MN	Active
DSH240084CP	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / General Surgery	730 E 34TH ST	HIBBING	MN	Active
DSH240084CQ	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Orthopedic Surgery	730 E 34TH ST	HIBBING	MN	Active
DSH240084CR	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Gastroenterology	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084CS	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Hematology/Oncology	730 E 34TH ST	HIBBING	MN	Active
DSH240084CT	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Anticoagulation Management	730 E 34TH ST	HIBBING	MN	Terminated
DSH240084CU	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Family Practice - AUR	1101 9TH ST N	VIRGINIA	MN	Terminated
DSH240084CV	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Heatlh Virginia Clinic / Occupational Medicine	1101 9TH ST N	VIRGINIA	MN	Terminated
DSH240084CW	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Family Practice - GRCL	1101 9TH ST N	VIRGINIA	MN	Terminated
DSH240084CX	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Vascular Diagnostics	730 E 34TH ST	HIBBING	MN	Terminated
DSH240084CY	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Occupational Therapy	730 E 34TH ST	HIBBING	MN	Active
DSH240084D	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Ambulatory Infusion Ctr - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084DE	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic - Essentia Health Virginia Clinic / Urology - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084DF	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic - Essentia Health Virginia Clinic / Integrative Health - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084DG	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / General Radiology - Essentia Health International Falls Clinic / General Radiology	2501 KEENAN DR	International Falls	MN	Active
DSH240084DJ	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / MRI - Essentia Health International Falls Clinic / MRI	2501 KEENAN DR	International Falls	MN	Active
DSH240084DK	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / Breast Center - Essentia Health International Falls Clinic / Breast Center	2501 KEENAN DR	International Falls	MN	Active
DSH240084DL	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / Audiology - Essentia Health Hibbing Clinic / Audiology	730 E 34TH ST	Hibbing	MN	Active
DSH240084DN	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / CAT - Essentia Health International Falls Clinic / CAT	2501 KEENAN DR	International Falls	MN	Active
DSH240084DP	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / Clinic Pharm Withdrawal - Essentia Health International Falls Clinic / Clinic Pharm Withdrawal	2501 KEENAN DR	International Falls	MN	Active
DSH240084DQ	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Echocardiography - Essentia Health Virginia Clinic / Echocardiography	1101 9TH ST N	Virginia	MN	Active
DSH240084DR	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / Ultrasound - Essentia Health International Falls Clinic / Ultrasound	2501 KEENAN DR	International Falls	MN	Active
DSH240084DS	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Ely Clinic / - OBGyn	300 W CONAN ST	ELY	MN	Active
DSH240084DT	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Ely Clinic / - Clinic Pharm Withdrawal	300 W CONAN ST	ELY	MN	Active
DSH240084DU	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / - Orthopedic Surgery	2501 KEENAN DR	INTERNATIONAL FALLS	MN	Active
DSH240084DV	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / - OBGyn	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084DW	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / - General Radiology - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084DX	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / - General Radiation - HIBB	730 E 34TH ST	HIBBING	MN	Active
DSH240084DY	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health International Falls Clinic / - Elder Care - IFAL	2501 KEENAN DR	INTERNATIONAL FALLS	MN	Active
DSH240084DZ	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / - CAT - HIBB	730 E 34TH ST	HIBBING	MN	Active
DSH240084E	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Rheumatology Osteo - VIR	1101 9th Street North	Virginia	MN	Terminated
DSH240084EA	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Hibbing Clinic / - IV - HIBB	730 E 34TH ST	HIBBING	MN	Active
DSH240084EB	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / - Radiology - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084EC	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Ely Clinic / - Weight Management - ELY	300 W CONAN ST	ELY	MN	Active
DSH240084ED	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / - Endocrinology - VIR	1101 9TH S N	VIRGINIA	MN	Active
DSH240084EE	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic - MSK Ultrasound - VIR	1101 9TH S N	VIRGINIA	MN	Active
DSH240084F	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Non-Invasive - VIR	1101 9th Street North	Virginia	MN	Terminated
DSH240084G	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Breast Center - VIR	1101 9th Street North	Virginia	MN	Terminated
DSH240084H	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Endocrinology/Diabetes - VIR	1101 9th Street North	Virginia	MN	Active
DSH240084J	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Family Practice - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084K	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / MSHO - VIR	1101 9th Street North	Virginia	MN	Terminated
DSH240084L	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Anticoagulation Mgmt - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084M	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Surgery Ortho - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084N	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Pain Management - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084P	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Cardiology	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084Q	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Urology - VIR	1101 9th Street North	Virginia	MN	Terminated
DSH240084R	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Ophthalmology - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084S	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / OB & Gynecology VIR	1101 9th Street North	Virginia	MN	Terminated
DSH240084T	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / General Surgery - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084U	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / General Internal Medicine - VIR	1101 9th Street North	Virginia	MN	Terminated
DSH240084V	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / General Pediatrics VIR	1101 9th Street North	Virginia	MN	Terminated
DSH240084W	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Dermatology - VIR	1101 9TH ST N	VIRGINIA	MN	Active
DSH240084X	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Fam/Genl Practice - Hibbing	1101 9th Street North	Virginia	MN	Terminated
DSH240084Y	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / General Pediatrics - Hibbing	1101 9th Street North	Virginia	MN	Terminated
DSH240084Z	Child	DSH	ESSENTIA HEALTH VIRGINIA	Essentia Health Virginia Clinic / Fam/Genl Practice - Ely	1101 9th Street North	Virginia	MN	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/30/2024 11:34:23 AM	8/30/2024 11:34 AM
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	2/26/2024 9:24 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	11/3/2023 9:27 AM
Details	State	Update		Approved	Active	10/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Stone, Sam COO Essentia Health 2187428600-2496	8/18/2023 7:39 AM
Details	340B ID	Update	New Registration		DSH240084DT	8/18/2023 7:39 AM
Details	Entity Subname	Update	New Registration	Essentia Health Ely Clinic /	Essentia Health Ely Clinic / - Clinic Pharm Withdrawal	8/18/2023 7:39 AM
Dates	Participating Approval Date	Update	New Registration		8/18/2023 7:39:52 AM	8/18/2023 7:39 AM
Details	State	Update	New Registration	Pending	Approved	8/18/2023 7:39 AM
Dates	Signed By Date	Update	New Registration		7/8/2023 2:13:04 PM	8/18/2023 7:39 AM
Dates	Start Date	Update	New Registration		10/1/2023 12:00:00 AM	8/18/2023 7:39 AM
Addresses	Main Address	Insert	New Registration		300 W CONAN ST ELY, MN 55731	7/1/2023 10:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1326598418	7/1/2023 10:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/1/2023 10:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083617120	7/1/2023 10:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/1/2023 10:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083617120	7/1/2023 10:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/1/2023 10:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1326598418	7/1/2023 10:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/1/2023 10:32 AM
Contacts	Authorizing Official	Insert	New Registration		Stone, Sam COO Essentia Health 2187428600-2496	7/1/2023 10:32 AM
Contacts	Primary Contact	Insert	New Registration		Sedlachek, Andrea 340B Senior Coordinator Essentia Health 2183936699	7/1/2023 10:32 AM
Details	Assistance Received From Date	Insert	New Registration			7/1/2023 10:32 AM
Details	Assistance Received To Date	Insert	New Registration			7/1/2023 10:32 AM
Details	Last Recertification Date	Insert	New Registration			7/1/2023 10:32 AM
Details	Grant Number	Insert	New Registration			7/1/2023 10:32 AM
Details	340B ID	Insert	New Registration			7/1/2023 10:32 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/1/2023 10:32 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/1/2023 10:32 AM
Details	Medicare Provider Number	Insert	New Registration		240084	7/1/2023 10:32 AM
Details	Entity Name	Insert	New Registration		ESSENTIA HEALTH VIRGINIA	7/1/2023 10:32 AM
Details	NOFO Number	Insert	New Registration			7/1/2023 10:32 AM
Details	Program Code	Insert	New Registration		DSH	7/1/2023 10:32 AM
Details	Entity Subname	Insert	New Registration		Essentia Health Ely Clinic /	7/1/2023 10:32 AM
Dates	Participating Approval Date	Insert	New Registration			7/1/2023 10:32 AM
Details	State	Insert	New Registration		Pending	7/1/2023 10:32 AM
Dates	Registration Date	Insert	New Registration		7/1/2023 10:32:31 AM	7/1/2023 10:32 AM
Dates	Signed By Date	Insert	New Registration			7/1/2023 10:32 AM
Dates	Start Date	Insert	New Registration			7/1/2023 10:32 AM
Terminations	Termination Comments	Insert	New Registration			7/1/2023 10:32 AM
Terminations	Termination Date	Insert	New Registration			7/1/2023 10:32 AM
Terminations	Termination Effective Date	Insert	New Registration			7/1/2023 10:32 AM
Terminations	Termination Reason	Insert	New Registration			7/1/2023 10:32 AM