Covered Entity Details

CAH131321-00 ST. MARYS HOSPITAL (Active) - information as of 5/17/2025 10:48:16 PM

Main Details

Name

ST. MARYS HOSPITAL

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH131321-00

Medicare Provider Number

131321

Additional Details

Current Program Status

Active

Registration Date

1/10/2019

Participating Start Date

4/1/2019

Participating Approval Date

1/14/2019

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Clearwater Valley Hospital/St. Mary's Hospital
Jyl Lyn Ruland, CFO
(208) 476-8062

Primary Contact

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

Addresses

Street Address

701 LEWISTON ST.
COTTONWOOD, ID 83522-0137

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Initial start date 9/30/2010, Termination 4/1/2018, reinstatement 4/1/2019	01/14/2019

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 CLINIC CANCER SERVICES PHARMACY
700 W IRONWOOD DR #228
COEUR D'ALENE, ID 83814-2656

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ARNZEN 'S KAMIAH DRUG	318 MAIN STREET	PO BOX 787	KAMIAH	ID	83536	04/14/2021	07/01/2021		07/01/2021
Contract Detail	ARNZEN DRUG	ROD F ARNZEN	PO BOX 7 429 MAIN	COTTONWOOD	ID	83522-0007	04/14/2021	07/01/2021		07/01/2021
Contract Detail	ARNZEN'S GLENWOOD PHARMACY	1105 MICHIGAN AVE		OROFINO	ID	83544	04/14/2021	07/01/2021	11/16/2023	01/03/2024
Contract Detail	IRWIN DRUG INC.	146 W MAIN ST.		GRANGEVILLE	ID	83530	04/14/2021	07/01/2021		07/01/2021
Contract Detail	KOOTENAI CLINICS CANCER SERVICES	PHARMACY	700 W IRONWOOD DR STE 228	COEUR D ALENE	ID	83814	01/23/2021	04/01/2021	04/02/2021	03/28/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH131321-01	Child	CAH	ST. MARYS HOSPITAL	KAMIAH MEDICAL CLINIC / Family Practice	518 OAK STREET	KAMIAH	ID	Active
CAH131321-02	Child	CAH	ST. MARYS HOSPITAL	NEZ PERCE MEDICAL CLINIC / Family Practice	501 OAK STREET	NEZ PERCE	ID	Active
CAH131321-03	Child	CAH	ST. MARYS HOSPITAL	CRAIGMONT MEDICAL CLINIC / Family Practice	320 N. DIVISION	CRAIGMONT	ID	Active
CAH131321-04	Child	CAH	ST. MARY'S HOSPITAL	ST. MARY'S HOSPITAL CLINIC	701 LEWISTON STREET	COTTONWOOD	ID	Terminated
CAH131321-05	Child	CAH	ST. MARYS HOSPITAL	GRANGEVILLE MEDICAL CLINIC / Family Practice	617 West North 2nd Ste 2	Grangeville	ID	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 8:09:36 AM	8/19/2024 12:21:32 PM	8/19/2024 12:21 PM
Details	Last Recertification Date	Update	Recertification	9/15/2022 7:38:57 AM	8/23/2023 8:09:36 AM	8/23/2023 8:09 AM
Addresses	Shipping Address	Insert	Change Request		KOOTENAI CLINIC CANCER SERVICES PHARMACY 700 W IRONWOOD DR #228 COEUR D'ALENE, ID 83814-2656	9/28/2022 1:22 PM
Details	Last Recertification Date	Update	Recertification	9/1/2021 2:08:53 PM	9/15/2022 7:38:57 AM	9/15/2022 7:38 AM
Contacts	Authorizing Official	Update	Change Request	Ruland, Jyl CFO Clearwater Valley Hospital and St. Mary's Hospital 2084768062	Ruland, Jyl Lyn CFO Clearwater Valley Hospital/St. Mary's Hospital 2084768062	6/10/2022 8:25 AM
Details	Last Recertification Date	Update	Recertification	9/10/2020 1:36:12 PM	9/1/2021 2:08:53 PM	9/1/2021 2:08 PM
Contacts	Primary Contact	Update	Change Request	Carr, Jennifer Director of Pharmacy Kootenai Health 2086255650	McDonald, Jim Pharmacy - 340B Program Manager Kootenai Health 2086255653	1/25/2021 10:34 AM
Details	Last Recertification Date	Update	Recertification	8/30/2019 11:38:05 AM	9/10/2020 1:36:12 PM	9/10/2020 1:36 PM
Contacts	Primary Contact	Update	Change Request	Lundberg, Bryan 340b Program Manager Essentia 2185760745	Carr, Jennifer Director of Pharmacy Kootenai Health 2086255650	3/15/2020 10:18 AM
Contacts	Authorizing Official	Update	Profile Change Request	Ruland, Jyl CFO Essentia Health 2084768062	Ruland, Jyl CFO Clearwater Valley Hospital and St. Mary's Hospital 2084768062	3/6/2020 4:28 PM
Contacts	Signed By	Update	Profile Change Request	Ruland, Jyl CFO Essentia Health 2084768062	Ruland, Jyl CFO Clearwater Valley Hospital and St. Mary's Hospital 2084768062	3/6/2020 4:28 PM
Details	Last Recertification Date	Update	Recertification		8/30/2019 11:38:05 AM	8/30/2019 11:38 AM
Details	State	Update		Approved	Active	4/1/2019 12:05 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	002283300 (ID)		2/20/2019 6:55 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841292307 ( )		2/20/2019 6:55 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1174577100 ( )		2/20/2019 6:55 PM
Contacts	Signed By	Insert	Reinstatement		Ruland, Jyl CFO Essentia Health 2084768062	1/14/2019 11:11 AM
Details	Entity Name	Update	Reinstatement	ST. MARY'S HOSPITAL	ST. MARYS HOSPITAL	1/14/2019 11:11 AM
Dates	Participating Approval Date	Update	Reinstatement		1/14/2019 11:11:25 AM	1/14/2019 11:11 AM
Details	State	Update	Reinstatement	Pending	Approved	1/14/2019 11:11 AM
Dates	Signed By Date	Update	Reinstatement	9/29/2010 12:00:00 AM	1/11/2019 11:03:40 AM	1/14/2019 11:11 AM
Dates	Start Date	Update	Reinstatement		4/1/2019 12:00:00 AM	1/14/2019 11:11 AM
Details	Comments Public	Insert	Reinstatement		Initial start date 9/30/2010, Termination 4/1/2018, reinstatement 4/1/2019	1/14/2019 11:06 AM
Addresses	Main Address	Update	Recertification	701 LEWISTON STREET COTTONWOOD, ID 83522	701 LEWISTON ST. COTTONWOOD, ID 83522-0137	1/10/2019 4:34 PM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1174577100	1/10/2019 4:34 PM
Details	Last Recertification Date	Update	Reinstatement	11/29/2017 6:56:57 AM		1/10/2019 4:34 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	3/29/2018 12:00:00 AM		1/10/2019 4:34 PM
Dates	Participating Approval Date	Update	Reinstatement	9/29/2010 12:00:00 AM		1/10/2019 4:34 PM
Details	State	Update	Reinstatement	Terminated	Pending	1/10/2019 4:34 PM
Dates	Registration Date	Update	Reinstatement	9/29/2010 12:00:00 AM	1/10/2019 4:34:08 PM	1/10/2019 4:34 PM
Dates	Start Date	Update	Reinstatement	9/30/2010 12:00:00 AM		1/10/2019 4:34 PM
Terminations	Termination Date	Update	Reinstatement	4/1/2018 12:00:00 AM		1/10/2019 4:34 PM
Terminations	Termination Effective Date	Update	Reinstatement	4/1/2018 12:00:00 AM		1/10/2019 4:34 PM
Terminations	Termination Reason	Update	Reinstatement	Business decision by the Covered Entity		1/10/2019 4:34 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		3/29/2018 12:00:00 AM	3/28/2018 12:36 PM
Details	State	Update	Termination Request	Active	To Be Terminated	3/28/2018 12:36 PM
Terminations	Termination Date	Update	Termination Request		4/1/2018 12:00:00 AM	3/28/2018 12:36 PM
Terminations	Termination Effective Date	Update	Termination Request		4/1/2018 12:00:00 AM	3/28/2018 12:36 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	3/28/2018 12:36 PM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	11/29/2017 6:56:57 AM	11/29/2017 6:56 AM
Contacts	Authorizing Official	Update		Ruland, Jyl CFO 2084768062	Ruland, Jyl CFO Essentia Health 2084768062	10/18/2017 12:09 PM
Contacts	Primary Contact	Update		Lundberg, Bryan 340b Program Manager 2185760745	Lundberg, Bryan 340b Program Manager Essentia 2185760745	9/20/2017 3:06 PM
Contacts	Authorizing Official	Update		Bonner, Lenne CFO 2084768008	Ruland, Jyl CFO 2084768062	8/14/2017 1:06 PM
Contacts	Primary Contact	Update		Henry, Shane Pharmacist 2084515187	Lundberg, Bryan 340b Program Manager 2185760745	8/14/2017 1:06 PM
Addresses	Main Address	Insert			701 LEWISTON STREET COTTONWOOD, ID 83522	8/14/2017 1:00 PM
Addresses	Billing Address	Insert			,	8/14/2017 1:00 PM
Details	Last Recertification Date	Update		9/3/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 8:50 AM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	9/3/2015 2:53 PM
Details	Last Recertification Date	Update		8/6/2014 12:00:00 AM	9/3/2015 12:00:00 AM	9/3/2015 2:53 PM
Contacts	Authorizing Official	Update		BARKER, LARRY COO 2084764555	Bonner, Lenne CFO 2084768008	8/7/2014 7:31 AM
Details	Last Recertification Date	Update		9/12/2013 12:00:00 AM	8/6/2014 12:00:00 AM	8/6/2014 5:42 PM
Contacts	Primary Contact	Update		BARKER, LARRY COO 2084764555	Henry, Shane Pharmacist 2084515187	9/12/2013 5:31 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/12/2013 12:00:00 AM	9/12/2013 5:27 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/16/2012 8:23 AM
Contacts	Authorizing Official	Insert			BARKER, LARRY COO 2084764555	3/10/2011 1:31 PM
Contacts	Primary Contact	Insert			BARKER, LARRY COO 2084764555	3/10/2011 1:31 PM
Details	Last Recertification Date	Insert				9/30/2010 8:01 AM
Details	Grant Number	Insert				9/30/2010 8:01 AM
Details	340B ID	Insert			CAH131321-00	9/30/2010 8:01 AM
Details	Is Authorizing Official EHB Data	Insert				9/30/2010 8:01 AM
Dates	Last Date That 340B Drugs Purchased	Insert				9/30/2010 8:01 AM
Details	Medicare Provider Number	Insert			131321	9/30/2010 8:01 AM
Details	Entity Name	Insert			ST. MARY'S HOSPITAL	9/30/2010 8:01 AM
Details	Program Code	Insert			CAH	9/30/2010 8:01 AM
Details	Entity Subname	Insert				9/30/2010 8:01 AM
Dates	Participating Approval Date	Insert			9/29/2010 12:00:00 AM	9/30/2010 8:01 AM
Details	State	Insert			Active	9/30/2010 8:01 AM
Dates	Registration Date	Insert			9/29/2010 12:00:00 AM	9/30/2010 8:01 AM
Dates	Signed By Date	Insert			9/29/2010 12:00:00 AM	9/30/2010 8:01 AM
Dates	Start Date	Insert			9/30/2010 12:00:00 AM	9/30/2010 8:01 AM
Terminations	Termination Comments	Insert				9/30/2010 8:01 AM
Terminations	Termination Date	Insert				9/30/2010 8:01 AM
Terminations	Termination Effective Date	Insert				9/30/2010 8:01 AM
Terminations	Termination Reason	Insert				9/30/2010 8:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert			True	9/29/2010 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			002283300	9/29/2010 5:46 PM
Medicaid Billing	Medicaid: State	Insert			ID	9/29/2010 5:46 PM
Medicaid Billing	NPI: Number	Insert			1841292307	9/29/2010 5:46 PM