Covered Entity Details

RRC130049-54 KOOTENAI HEALTH INC (Approved) - information as of 5/9/2025 10:46:00 PM

Main Details

Name

KOOTENAI HEALTH INC

Subdivision Name

KOOTENAI CLINIC LUNG & ASTHMA - LUNG & ASTHMA

Type

Rural Referral Center

Rural

340B ID

RRC130049-54

Medicare Provider Number

130049

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/11/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/29/2025

Last Recertification Date

Contacts

Authorizing Official

Kootenai Health
Michele Bouit, CFO
(208) 625-4004

Primary Contact

Kootenai Health
Jim McDonald, Pharmacy - 340B Program Manager
(208) 625-5653

Addresses

Street Address

700 W Ironwood Drive
Suite 378
Coeur D Alene, ID 83814

Billing Address

Kootenai Health
2003 Kootenai Health Way
Coeur D Alene, ID 83814

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

Kootenai Health
2003 Kootenai Health Way
Coeur D Alene, ID 83814

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
RRC130049-01	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CANCER CENTER-COEUR D' ALENE	700 IRONWOOD # 130	COEUR D'ALENE	ID	Approved
RRC130049-02	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CANCER CENTER-POST FALLS	1440 EAST MULLAN AVE	POST FALLS	ID	Approved
RRC130049-03	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CANCER CENTER AT BONNER GENERAL	520 NORTH 3RD AVE	SANDPOINT	ID	Approved
RRC130049-13	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC VASCULARY SURGERY - VASCULAR	700 W IRONWOOD DR	COEUR D' ALENE	ID	Approved
RRC130049-14	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC - SLEEP MEDICINE - SLEEP	2100 IRONWOOD CT	COEUR D' ALENE	ID	Terminated
RRC130049-15	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC NEPHROLOGY - NEPHROLOGY	700 W IRONWOOD DR	COEUR D' ALENE	ID	Approved
RRC130049-16	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC PLASTIC AND RECONSTRUCTIVE SURGERY - DERMATOLOGY - RECONSTRUCTIVE SURGERY AND DERMATOLOGY	980 Ironwood Dr.	Coeur d'Alene	ID	Approved
RRC130049-17	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC DIABETES AND ENDOCRINOLOGY - DIABETES AND ENDOCRINOLOGY	1919 LINCOLN WAY	COEUR D'ALENE	ID	Approved
RRC130049-19	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC GENERAL SURGERY - GENERAL SURGERY	700 W IRONWOOD DR	COEUR D' ALENE	ID	Approved
RRC130049-20	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC PSYCHIATRY - PSYCHIATRY	2199 IRONWOOD CENTER DRIVE	COEUR D'ALENE	ID	Terminated
RRC130049-21	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC GASTROENTEROLOGY - GASTROENTEROLOGY	1919 LINCOLN WAY	COEUR D'ALENE	ID	Approved
RRC130049-22	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC RHEUMATOLOGY - RHEUMATOLOGY	700 W IRONWOOD DR	COEUR D'ALENE	ID	Approved
RRC130049-23	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC NEUROSURGERY - NEUROSURGERY	700 W IRONWOOD DR	COEUR D'ALENE	ID	Terminated
RRC130049-24	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC WOUND CARE AND INFECTIOUS DISEASE - Wound Care, Infectious Disease	2120 W. Ironwood Dr.	Coeur d'Alene	ID	Terminated
RRC130049-25	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC OBSTETRICS & GYNECOLOGY - OBSTETRICS & GYNECOLOGY	1300 E MULLAN AVE	POST FALLS	ID	Approved
RRC130049-26	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC - ORTHOPEDICS POST FALLS - ORTHOPEDICS	1296 E POLSTON AVE	POST FALLS	ID	Approved
RRC130049-27	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC EAR NOSE THROAT & ALLERGY - ENT	700 W IRONWOOD DR	COEUR D' ALENE	ID	Approved
RRC130049-28	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI HEART CLINICS NORTHWEST - CARDIOLOGY	1300 E MULLAN AVE 900	POST FALLS	ID	Approved
RRC130049-29	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE - FAMILY MEDICINE	566 W PRAIRIE AVENUE	Coeur d'Alene	ID	Approved
RRC130049-30	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE - FAMILY MEDICINE	1701 LINCOLN WAY	COEUR D'ALENE	ID	Approved
RRC130049-31	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE - FAMILY MEDICINE	1300 E MULLAN AVE #1300	POST FALLS	ID	Approved
RRC130049-32	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC INTERNAL MEDICINE - INTERNAL MEDICINE	1919 LINCOLN WAY	COEUR D'ALENE	ID	Approved
RRC130049-33	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEART CLINICS NORTHWEST - CARDIOLOGY	13102 E MISSION AVE	SPOKANE VALLEY	WA	Terminated
RRC130049-34	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC NEUROLOGY - NEUROLOGY	700 Ironwood Dr. #158	Coeur d'Alene	ID	Approved
RRC130049-35	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEART CLINICS NORTHWEST - CARDIOLOGY	122 W 7TH AVE	SPOKANE	WA	Terminated
RRC130049-36	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC CANCER SERVICES - Infusion Center	700 W IRONWOOD DR	COEUR D'ALENE	ID	Approved
RRC130049-37	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEART CLINICS NORTHWEST - CARDIOLOGY	212 E CENTRAL	SPOKANE	WA	Terminated
RRC130049-38	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEALTH - ADVANCED HEART DISEASE MANAGEMENT CLINIC/ELECTROPHYSIOLOGY - CARDIOLOGY	700 W IRONWOOD DR	COEUR D'ALENE	ID	Terminated
RRC130049-39	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC HAND SURGERY - HAND SURGERY	2121 W IRONWOOD DR.	COEUR D' ALENE	ID	Terminated
RRC130049-40	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC INTERNAL MEDICINE - INTERNAL MEDICINE	1300 E MULLAN AVE	POST FALLS	ID	Approved
RRC130049-41	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC GASTROENTEROLOGY & ENDOSCOPY - GASTROENTEROLOGY & ENDOSCOPY	1919 LINCOLN WAY	COEUR D'ALENE	ID	Approved
RRC130049-42	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC ORTHOPEDICS - ORTHOPEDICS	1110 W PARK PL	COEUR D' ALENE	ID	Terminated
RRC130049-43	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC - ENT & ALLERGY - ENT	420 N 2ND AVE	SANDPOINT	ID	Terminated
RRC130049-44	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC OBSTETRICS & GYNECOLOGY - OBSTETRICS & GYNECOLOGY	980 IRONWOOD DR	COEUR D' ALENE	ID	Approved
RRC130049-45	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC INTERNAL MEDICINE - INTERNAL MEDICINE	1701 LINCOLN WAY	COEUR D'ALENE	ID	Terminated
RRC130049-46	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI HEART CLINICS NORTHWEST - CARDIOLOGY	700 W IRONWOOD DR	COEUR D'ALENE	ID	Approved
RRC130049-47	Child	RRC	KOOTENAI HOSPITAL DISTRICT	MCGRANE CENTER FOR REHABILITATION - PHYSICAL THERAPY	2003 Kootenai Health Way	Coeur d'Alene	ID	Terminated
RRC130049-48	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI OUTPATIENT IMAGING - RADIOLOGY	1919 LINCOLN WAY	COEUR D'ALENE	ID	Terminated
RRC130049-49	Child	RRC	KOOTENAI HOSPITAL DISTRICT	KOOTENAI OUTPATIENT IMAGING - RADIOLOGY	700W IRONWOOD DR	COEUR D'ALENE	ID	Terminated
RRC130049-50	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE CDA RESIDENCY - FAMILY MEDICINE	1919 LINCOLN WAY	COEUR D'ALENE	ID	Approved
RRC130049-51	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI HEALTH - ANTICOAGULATION CLINIC - ANTICOAGULATION	700 IRONWOOD DRIVE	COEUR D' ALENE	ID	Approved
RRC130049-52	Child	RRC	KOOTENAI HEALTH INC	Kootenai Clinic - Orthopedics - Orthopedics	2177 W. Ironwood Center Drive	Coeur D Alene	ID	Approved
RRC130049-53	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE CDA IRONWOOD - FAMILY MEDICINE	914 W Ironwood Drive	Coeur D Alene	ID	Approved
RRC130049-54	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC LUNG & ASTHMA - LUNG & ASTHMA	700 W Ironwood Drive	Coeur D Alene	ID	Approved
RRC130049-55	Child	RRC	KOOTENAI HEALTH INC	KOOTENAI CLINIC - SLEEP MEDICINE - SLEEP MEDICINE	700 IRONWOOD DRIVE	COEUR D'ALENE	ID	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Change Request	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEALTH INC	5/7/2025 6:18 AM
Contacts	Signed By	Insert	New Registration		Bouit, Michele CFO Kootenai Health 2086254004	4/29/2025 10:18 AM
Details	340B ID	Update	New Registration		RRC130049-54	4/29/2025 10:18 AM
Details	Entity Subname	Update	New Registration	KOOTENAI CLINIC LUNG & ASTHMA	KOOTENAI CLINIC LUNG & ASTHMA - LUNG & ASTHMA	4/29/2025 10:18 AM
Dates	Participating Approval Date	Update	New Registration		4/29/2025 10:18:49 AM	4/29/2025 10:18 AM
Details	State	Update	New Registration	Pending	Approved	4/29/2025 10:18 AM
Dates	Signed By Date	Update	New Registration		4/14/2025 5:42:32 PM	4/29/2025 10:18 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/29/2025 10:18 AM
Addresses	Main Address	Insert	New Registration		700 W Ironwood Drive Suite 378 Coeur D Alene, ID 83814	4/11/2025 4:19 PM
Addresses	Billing Address	Insert	New Registration		Kootenai Health 2003 Kootenai Health Way Coeur D Alene, ID 83814	4/11/2025 4:19 PM
Addresses	Shipping Address	Insert	New Registration		Kootenai Health 2003 Kootenai Health Way Coeur D Alene, ID 83814	4/11/2025 4:19 PM
Contacts	Primary Contact	Insert	New Registration		McDonald, Jim Pharmacy - 340B Program Manager Kootenai Health 2086255653	4/11/2025 4:19 PM
Contacts	Authorizing Official	Insert	New Registration		Bouit, Michele CFO Kootenai Health 2086254004	4/11/2025 4:19 PM
Details	Assistance Received From Date	Insert	New Registration			4/11/2025 4:19 PM
Details	Assistance Received To Date	Insert	New Registration			4/11/2025 4:19 PM
Details	Last Recertification Date	Insert	New Registration			4/11/2025 4:19 PM
Details	Grant Number	Insert	New Registration			4/11/2025 4:19 PM
Details	340B ID	Insert	New Registration			4/11/2025 4:19 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/11/2025 4:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/11/2025 4:19 PM
Details	Medicare Provider Number	Insert	New Registration		130049	4/11/2025 4:19 PM
Details	Entity Name	Insert	New Registration		KOOTENAI HOSPITAL DISTRICT	4/11/2025 4:19 PM
Details	NOFO Number	Insert	New Registration			4/11/2025 4:19 PM
Details	Program Code	Insert	New Registration		RRC	4/11/2025 4:19 PM
Details	Entity Subname	Insert	New Registration		KOOTENAI CLINIC LUNG & ASTHMA	4/11/2025 4:19 PM
Dates	Participating Approval Date	Insert	New Registration			4/11/2025 4:19 PM
Details	State	Insert	New Registration		Pending	4/11/2025 4:19 PM
Dates	Registration Date	Insert	New Registration		4/11/2025 4:19:42 PM	4/11/2025 4:19 PM
Dates	Signed By Date	Insert	New Registration			4/11/2025 4:19 PM
Dates	Start Date	Insert	New Registration			4/11/2025 4:19 PM
Terminations	Termination Comments	Insert	New Registration			4/11/2025 4:19 PM
Terminations	Termination Date	Insert	New Registration			4/11/2025 4:19 PM
Terminations	Termination Effective Date	Insert	New Registration			4/11/2025 4:19 PM
Terminations	Termination Reason	Insert	New Registration			4/11/2025 4:19 PM