Covered Entity Details

DSH130025M MADISON MEMORIAL HOSPITAL (Active) - information as of 4/25/2025 8:32:47 PM

Main Details

Name

MADISON MEMORIAL HOSPITAL

Subdivision Name

Seasons Medical Center - Behavioral Health Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH130025M

Medicare Provider Number

130025

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2025

Participating Start Date

4/1/2025

Participating Approval Date

1/27/2025

Last Recertification Date

Contacts

Authorizing Official

Madison Memorial Hospital
Rachel Gonzales, CEO
(208) 356-3691

Primary Contact

Madison Memorial Hospital
David A Kennedy, Pharmacy Director
(208) 359-6484

Addresses

Street Address

37 S 2nd East
Rexburg, ID 83440

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?
No

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
DSH130025A	Child	DSH	MADISON MEMORIAL HOSPITAL	MADISON MEMORIAL SURGERY CENTER	381 E 4TH N	REXBURG	ID	Active
DSH130025B	Child	DSH	MADISON MEMORIAL HOSPITAL	MADISON MEMORIAL REXBURG MED CLINIC	393 E 2 ND N	REXBURG	ID	Active
DSH130025C	Child	DSH	MADISON MEMORIAL HOSPITAL	Seasons Medical Center - Family Practice	37 South 2nd East	Rexburg	ID	Terminated
DSH130025D	Child	DSH	MADISON MEMORIAL HOSPITAL	Madison Memorial - Orthopedics	393 E 2nd N	Rexburg	ID	Active
DSH130025E	Child	DSH	MADISON MEMORIAL HOSPITAL	Seasons Medical Center - Pediatric	37 South 2nd East	Rexburg	ID	Active
DSH130025F	Child	DSH	MADISON MEMORIAL HOSPITAL	Seasons Medical Center - Womens Center	37 South 2nd East	Rexburg	ID	Active
DSH130025G	Child	DSH	MADISON MEMORIAL HOSPITAL	Seasons Medical Center - Family Medicine	37 South 2nd East	Rexburg	ID	Active
DSH130025H	Child	DSH	MADISON MEMORIAL HOSPITAL	Seasons Medical Center - Internal Medicine	37 South 2nd East	Rexburg	ID	Active
DSH130025J	Child	DSH	MADISON MEMORIAL HOSPITAL	MADISON CO MEMORIAL HOSPITAL - Rigby Medical Center	477 PLEASANT COUNTY LN	RIGBY	ID	Active
DSH130025K	Child	DSH	MADISON MEMORIAL HOSPITAL	MADISON CO MEMORIAL HOSPITAL - Madison Foot and Ankle	25 MADISON PROFESSIONAL PARK	REXBURG	ID	Active
DSH130025L	Child	DSH	MADISON MEMORIAL HOSPITAL	Upper Valley - Orthopedics	360 E Main St	Rexburg	ID	Active
DSH130025M	Child	DSH	MADISON MEMORIAL HOSPITAL	Seasons Medical Center - Behavioral Health Clinic	37 S 2nd East	Rexburg	ID	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Gonzales, Rachel CEO Madison Memorial Hospital 2083563691	1/27/2025 8:20 AM
Details	340B ID	Update	New Registration		DSH130025M	1/27/2025 8:20 AM
Details	Entity Subname	Update	New Registration	Seasons Medical Center	Seasons Medical Center - Behavioral Health Clinic	1/27/2025 8:20 AM
Dates	Participating Approval Date	Update	New Registration		1/27/2025 8:20:53 AM	1/27/2025 8:20 AM
Details	State	Update	New Registration	Pending	Approved	1/27/2025 8:20 AM
Dates	Signed By Date	Update	New Registration		1/15/2025 5:21:43 PM	1/27/2025 8:20 AM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	1/27/2025 8:20 AM
Addresses	Main Address	Insert	New Registration		37 S 2nd East Rexburg, ID 83440	1/15/2025 5:05 PM
Contacts	Authorizing Official	Insert	New Registration		Gonzales, Rachel CEO Madison Memorial Hospital 2083563691	1/15/2025 5:05 PM
Contacts	Primary Contact	Insert	New Registration		Kennedy, David A Pharmacy Director Madison Memorial Hospital 2083596484	1/15/2025 5:05 PM
Details	Assistance Received From Date	Insert	New Registration			1/15/2025 5:05 PM
Details	Assistance Received To Date	Insert	New Registration			1/15/2025 5:05 PM
Details	Last Recertification Date	Insert	New Registration			1/15/2025 5:05 PM
Details	Grant Number	Insert	New Registration			1/15/2025 5:05 PM
Details	340B ID	Insert	New Registration			1/15/2025 5:05 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/15/2025 5:05 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/15/2025 5:05 PM
Details	Medicare Provider Number	Insert	New Registration		130025	1/15/2025 5:05 PM
Details	Entity Name	Insert	New Registration		MADISON MEMORIAL HOSPITAL	1/15/2025 5:05 PM
Details	NOFO Number	Insert	New Registration			1/15/2025 5:05 PM
Details	Program Code	Insert	New Registration		DSH	1/15/2025 5:05 PM
Details	Entity Subname	Insert	New Registration		Seasons Medical Center	1/15/2025 5:05 PM
Dates	Participating Approval Date	Insert	New Registration			1/15/2025 5:05 PM
Details	State	Insert	New Registration		Pending	1/15/2025 5:05 PM
Dates	Registration Date	Insert	New Registration		1/15/2025 5:05:52 PM	1/15/2025 5:05 PM
Dates	Signed By Date	Insert	New Registration			1/15/2025 5:05 PM
Dates	Start Date	Insert	New Registration			1/15/2025 5:05 PM
Terminations	Termination Comments	Insert	New Registration			1/15/2025 5:05 PM
Terminations	Termination Date	Insert	New Registration			1/15/2025 5:05 PM
Terminations	Termination Effective Date	Insert	New Registration			1/15/2025 5:05 PM
Terminations	Termination Reason	Insert	New Registration			1/15/2025 5:05 PM