Covered Entity Details

CAH131312-23 ST. LUKE'S MCCALL, LTD (Approved) - information as of 4/29/2025 4:36:18 AM

Main Details

Name

ST. LUKE'S MCCALL, LTD

Subdivision Name

ST LUKES MCCALL MEDICAL CENTER - ST LUKES CLINIC-PAIN MANAGEMENT

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH131312-23

Medicare Provider Number

131312

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/1/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/4/2025

Last Recertification Date

Contacts

Authorizing Official

St. Luke's Health System, LTD
Kate Fowler, Senior VP & CFO
(208) 381-8717

Primary Contact

St. Luke's Health System, LTD
Amanda Davis, Pharmacy Business Analyst
(208) 706-1021

Addresses

Street Address

211 FOREST ST
MCCALL, ID 83638-5256

Billing Address

St. Luke's Health System, LTD
190 E Bannock St.
BOISE, ID 83712

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

Shipping Address 1

ST. LUKE'S MCCALL, LTD
ATTN: PHARMACY
1000 STATE STREET
MCCALL, ID 83638

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
CAH131312-01	Child	CAH	ST. LUKE'S MCCALL, LTD	ST. LUKE'S CLINIC-MCCALL ORTHO SURGERY CLINIC	200 FOREST ST.	MCCALL	ID	Active
CAH131312-02	Child	CAH	ST. LUKE'S MCCALL, LTD	MCCALL GENERAL SURGERY CLINIC	200 FOREST ST.	MCCALL	ID	Active
CAH131312-03	Child	CAH	ST. LUKE'S MCCALL, LTD	ST LUKE'S CLINIC-MCCALL MEDICAL CLINIC	209 FOREST ST.	MCCALL	ID	Active
CAH131312-04	Child	CAH	ST. LUKE'S MCCALL, LTD	PAYETTE LAKES MEDICAL CLINIC-DL ST LUKES INTEGRATIVE MEDICINE	301 Deinhard Lane	MCCALL	ID	Terminated
CAH131312-05	Child	CAH	ST. LUKE'S MCCALL, LTD	ST LUKE'S CLINIC- PAYETTE LAKES MEDICAL CLINIC FAMILY MEDICINE	211 FOREST ST.	MCCALL	ID	Active
CAH131312-06	Child	CAH	ST. LUKE'S MCCALL, LTD	SL MEADOWS VALLEY MEDICAL CLINIC	320 VIRGINIA ST.	NEW MEADOWS	ID	Active
CAH131312-07	Child	CAH	ST. LUKE'S MCCALL, LTD	ST LUKES CLINC PAYETTE LAKE MEDICAL CLINIC / MOUNTAIN STATES UROLOGY-MCCALL	211 Forest St.	McCall	ID	Active
CAH131312-08	Child	CAH	ST. LUKE'S MCCALL, LTD	Sleep Lab - McCall St Lukes Sleep Medicine Institute-McCall	200 Forest Street	McCall	ID	Terminated
CAH131312-09	Child	CAH	ST. LUKE'S MCCALL, LTD	McCall Clinics - McCall Clinics/Payette Lakes Medical Clinic St. Lukes Integrative Medicine	211 Forest St.	McCall	ID	Terminated
CAH131312-10	Child	CAH	ST. LUKE'S MCCALL, LTD	PAYETTE LAKES MEDICAL CLINIC - ST LUKES OBSTETRICS AND GYNECOLOGY -MCCALL	211 FOREST STREET	McCall	ID	Active
CAH131312-11	Child	CAH	ST. LUKE'S MCCALL, LTD	ST LUKE'S CLINIC-SALMON RIVER FAMILY MEDICINE	214 MAIN STREET	Riggins	ID	Active
CAH131312-12	Child	CAH	ST. LUKE'S MCCALL, LTD	ST LUKE'S CLINIC - MCCALL MEDICAL CLINIC WOUND CARE	209 FOREST ST.	MCCALL	ID	Active
CAH131312-13	Child	CAH	ST. LUKE'S MCCALL, LTD	PHYSICAL THERAPY - SALMON RIVER MEDICAL CENTER ST LUKES PHYSICAL THERAPY-RIGGINS	214 N MAIN STREET	RIGGINS	ID	Active
CAH131312-14	Child	CAH	ST. LUKE'S MCCALL, LTD	ST LUKE'S CLINIC - BEHAVIORAL HEALTH MCCALL	301 DEINHARD LANE	MCCALL	ID	Active
CAH131312-15	Child	CAH	ST. LUKE'S MCCALL, LTD	PAYETTE LAKES MEDICAL CLINIC - MEADOWS VALLEY MEDICAL CLINIC INTEGRATIVE MEDICINE NEW MEADOWS	320 VIRGINIA AVENUE	NEW MEADOWS	ID	Terminated
CAH131312-16	Child	CAH	ST. LUKE'S MCCALL, LTD	PAYETTE LAKES MEDICAL CLINIC - PLMC ST LUKE'S IDAHO CARDIOLOGY ASSOCIATES-MCCALL	211 FOREST STREET	MCCALL	ID	Active
CAH131312-17	Child	CAH	ST. LUKE'S MCCALL, LTD	ST LUKE'S CLINIC-MCCALL MEDICAL CLINIC CLINICAL ONCOLOGY	209 FOREST STREET	MCCALL	ID	Active
CAH131312-18	Child	CAH	ST. LUKE'S MCCALL, LTD	PAYETTE LAKES MEDICAL CLINIC - ST LUKES RHEUMATOLOGY-MCCALL	211 FOREST ST.	MCCALL	ID	Terminated
CAH131312-19	Child	CAH	ST. LUKE'S MCCALL, LTD	PAYETTE LAKES MEDICAL CLINIC - ST LUKES CLINIC CHILDRENS CARDIOLOGY-MCCALL	211 FOREST ST.	MCCALL	ID	Terminated
CAH131312-20	Child	CAH	ST. LUKE'S MCCALL, LTD	ST LUKES PAYETTE LAKES MEDICAL CLINIC - ST LUKES CLINIC DERMATOLOGY	211 FOREST ST.	MCCALL	ID	Active
CAH131312-21	Child	CAH	ST. LUKE'S MCCALL, LTD	ST LUKES CLINIC BEHAVIORAL HEALTH - NEUROPSYCHOLOGY	301 DEINHARD LN	MCCALL	ID	Active
CAH131312-22	Child	CAH	ST. LUKE'S MCCALL, LTD	ST LUKE'S CLINIC MCCALL - QUICKCARE MCCALL	200 FOREST ST.	MCCALL	ID	Active
CAH131312-23	Child	CAH	ST. LUKE'S MCCALL, LTD	ST LUKES MCCALL MEDICAL CENTER - ST LUKES CLINIC-PAIN MANAGEMENT	211 FOREST ST	MCCALL	ID	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Fowler, Kate Senior VP & CFO St. Luke's Health System, LTD 2083818717	4/4/2025 9:04 AM
Details	340B ID	Update	New Registration		CAH131312-23	4/4/2025 9:04 AM
Details	Entity Subname	Update	New Registration	ST LUKES MCCALL MEDICAL CENTER	ST LUKES MCCALL MEDICAL CENTER - ST LUKES CLINIC-PAIN MANAGEMENT	4/4/2025 9:04 AM
Dates	Participating Approval Date	Update	New Registration		4/4/2025 9:04:16 AM	4/4/2025 9:04 AM
Details	State	Update	New Registration	Pending	Approved	4/4/2025 9:04 AM
Dates	Signed By Date	Update	New Registration		4/3/2025 4:52:23 PM	4/4/2025 9:04 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/4/2025 9:04 AM
Addresses	Main Address	Insert	New Registration		211 FOREST ST MCCALL, ID 83638-5256	4/1/2025 12:06 PM
Addresses	Billing Address	Insert	New Registration		St. Luke's Health System, LTD 190 E Bannock St. BOISE, ID 83712	4/1/2025 12:06 PM
Addresses	Shipping Address	Insert	New Registration		ST. LUKE'S MCCALL, LTD ATTN: PHARMACY 1000 STATE STREET MCCALL, ID 83638	4/1/2025 12:06 PM
Contacts	Primary Contact	Insert	New Registration		Davis, Amanda Pharmacy Business Analyst St. Luke's Health System, LTD 2087061021	4/1/2025 12:06 PM
Contacts	Authorizing Official	Insert	New Registration		Fowler, Kate Senior VP & CFO St. Luke's Health System, LTD 2083818717	4/1/2025 12:06 PM
Details	Assistance Received From Date	Insert	New Registration			4/1/2025 12:06 PM
Details	Assistance Received To Date	Insert	New Registration			4/1/2025 12:06 PM
Details	Last Recertification Date	Insert	New Registration			4/1/2025 12:06 PM
Details	Grant Number	Insert	New Registration			4/1/2025 12:06 PM
Details	340B ID	Insert	New Registration			4/1/2025 12:06 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2025 12:06 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2025 12:06 PM
Details	Medicare Provider Number	Insert	New Registration		131312	4/1/2025 12:06 PM
Details	Entity Name	Insert	New Registration		ST. LUKE'S MCCALL, LTD	4/1/2025 12:06 PM
Details	NOFO Number	Insert	New Registration			4/1/2025 12:06 PM
Details	Program Code	Insert	New Registration		CAH	4/1/2025 12:06 PM
Details	Entity Subname	Insert	New Registration		ST LUKES MCCALL MEDICAL CENTER	4/1/2025 12:06 PM
Dates	Participating Approval Date	Insert	New Registration			4/1/2025 12:06 PM
Details	State	Insert	New Registration		Pending	4/1/2025 12:06 PM
Dates	Registration Date	Insert	New Registration		4/1/2025 12:06:39 PM	4/1/2025 12:06 PM
Dates	Signed By Date	Insert	New Registration			4/1/2025 12:06 PM
Dates	Start Date	Insert	New Registration			4/1/2025 12:06 PM
Terminations	Termination Comments	Insert	New Registration			4/1/2025 12:06 PM
Terminations	Termination Date	Insert	New Registration			4/1/2025 12:06 PM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2025 12:06 PM
Terminations	Termination Reason	Insert	New Registration			4/1/2025 12:06 PM