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DSH240084A ESSENTIA HEALTH VIRGINIA (Terminated)
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Main Details
Name
ESSENTIA HEALTH VIRGINIA
Subdivision Name
Essentia Health Virginia Medical Arts Clinic / OB & Gynecology - VMAC (Medical Arts Clinic)
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH240084A
Medicare Provider Number
240084
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/14/2015
Participating Start Date
7/1/2015
Participating Approval Date
2/9/2015
Last Recertification Date
9/5/2015
Termination Date
Termination Reason
10/1/2015
Other
Contacts
Authorizing Official
Essentia Health
Sam Stone, COO
(218) 742-8600 Ext: 2496
Primary Contact
Essentia Health
Bryan Lundberg, 340b Program Manager
(218) 828-7143
Addresses
Street Address
901 9th Street North
Virginia, MN 55792
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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