Covered Entity Details

CAH131309-00 CARIBOU MEDICAL CENTER (Active) - information as of 4/29/2025 10:34:25 PM

Main Details

Name

CARIBOU MEDICAL CENTER

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH131309-00

Medicare Provider Number

131309

Additional Details

Current Program Status

Active

Registration Date

12/1/2010

Participating Start Date

4/1/2011

Participating Approval Date

1/31/2011

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Caribou Medical Center
Ryan D Speas, CFO
(208) 506-5785

Primary Contact

CARIBOU MEDICAL CENTER
Dillon Liechty, Interim CEO/COO
(208) 221-5154

Addresses

Street Address

300 SOUTH 3RD WEST
SODA SPRINGS, ID 83276

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

Shipping Address 1

CARIBOU MEMORIAL HOSPITAL
PHARMACY
300 SOUTH 3RD WEST
SODA SPRINGS, ID 83276

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	BROULIM'S PHARMACY	89 W 2ND S		SODA SPRINGS	ID	83276-1509	04/19/2013	07/01/2013		04/19/2013
Contract Detail	CENTERWELL PHARMACY, INC.	9843 WINDISCH RD		WEST CHESTER	OH	45069	10/13/2022	01/01/2023		01/01/2023
Contract Detail	EASTMAN DRUG COMPANY	116 SOUTH MAIN		SODA SPRINGS	ID	83276	07/14/2016	10/01/2016		07/14/2016
Contract Detail	LONDON DRUG	#6 SOUTH MAIN	BOX 325	GRACE	ID	83241	01/14/2016	04/01/2016	06/01/2016	06/06/2016
Contract Detail	LONDON DRUG LLC	6TH SOUTH MAIN	PO BOX 325	GRACE	ID	83241	07/01/2016	10/01/2016		07/01/2016

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
No records to display.

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/27/2023 4:43:50 PM	9/3/2024 3:17:24 PM	9/3/2024 3:17 PM
Contacts	Authorizing Official	Update	AO Change Request	Robinson, Alan CFO Caribou Memorial Hospital 2085473341-7006	Speas, Ryan D CFO Caribou Medical Center 2085065785	9/3/2024 1:56 PM
Contacts	Primary Contact	Update	Recertification	Thomas, Christina CEO Caribou Medical Center 2085472765	Liechty, Dillon Interim CEO/COO CARIBOU MEDICAL CENTER 2082215154	9/27/2023 4:43 PM
Details	Last Recertification Date	Update	Recertification	9/16/2022 2:45:37 PM	9/27/2023 4:43:50 PM	9/27/2023 4:43 PM
Contacts	Primary Contact	Update	Recertification	Cutler, Kenna Director, Pharmacy Caribou Memorial Hospital 2085473341-7250	Thomas, Christina CEO Caribou Medical Center 2085472765	9/16/2022 2:45 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 8:23:31 AM	9/16/2022 2:45:37 PM	9/16/2022 2:45 PM
Details	Last Recertification Date	Update	Recertification	8/27/2020 6:47:03 AM	9/7/2021 8:23:31 AM	9/7/2021 8:23 AM
Details	Entity Name	Update	Recertification	CARIBOU MEMORIAL HOSPITAL	CARIBOU MEDICAL CENTER	9/7/2021 8:23 AM
Details	Last Recertification Date	Update	Recertification	9/5/2019 7:44:22 AM	8/27/2020 6:47:03 AM	8/27/2020 6:47 AM
Contacts	Primary Contact	Update	Change Request	Cutler, Kenna Director, Pharmacy Caribou Memorial Hospital 2085473341	Cutler, Kenna Director, Pharmacy Caribou Memorial Hospital 2085473341-7250	3/26/2020 7:15 AM
Details	Last Recertification Date	Update	Recertification	9/5/2018 2:33:21 PM	9/5/2019 7:44:22 AM	9/5/2019 7:44 AM
Contacts	Authorizing Official	Update	AO Change Request	Marlowe, Cameron CFO Caribou Memorial Hospital 2085472917	Robinson, Alan CFO Caribou Memorial Hospital 2085473341-7006	3/25/2019 7:46 AM
Contacts	Primary Contact	Update	Change Request	Bartschi, Angie Clinic Manager Caribou Memorial Hospital 2085473341	Cutler, Kenna Director, Pharmacy Caribou Memorial Hospital 2085473341	9/18/2018 6:25 PM
Details	Last Recertification Date	Update	Recertification	12/5/2017 2:38:51 PM	9/5/2018 2:33:21 PM	9/5/2018 2:33 PM
Contacts	Authorizing Official	Update	AO Change Request	SMITH, JON CEO Caribou Memorial Hospital 2085472765	Marlowe, Cameron CFO Caribou Memorial Hospital 2085472917	9/5/2018 2:14 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	002863500 (ID)		12/5/2017 2:38 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1184752347 ( )		12/5/2017 2:38 PM
Contacts	Primary Contact	Update	Recertification	SMITH, JON CEO Caribou Memorial Hospital 2085472765	Bartschi, Angie Clinic Manager Caribou Memorial Hospital 2085473341	12/5/2017 2:38 PM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	12/5/2017 2:38:51 PM	12/5/2017 2:38 PM
Contacts	Authorizing Official	Update		SMITH, JON CEO 2085472765	SMITH, JON CEO Caribou Memorial Hospital 2085472765	10/26/2017 12:19 PM
Contacts	Primary Contact	Update		SMITH, JON CEO 2085472765	SMITH, JON CEO Caribou Memorial Hospital 2085472765	10/26/2017 12:19 PM
Addresses	Main Address	Insert			300 SOUTH 3RD WEST SODA SPRINGS, ID 83276	8/29/2016 9:01 PM
Contacts	Authorizing Official	Update		HOOPES, JOHN CEO 2085472780	SMITH, JON CEO 2085472765	8/29/2016 9:01 PM
Contacts	Primary Contact	Update		HOOPES, JOHN CEO 2085472780	SMITH, JON CEO 2085472765	8/29/2016 9:01 PM
Details	Last Recertification Date	Update		8/19/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/29/2016 9:00 PM
Details	Last Recertification Date	Update		8/29/2014 12:00:00 AM	8/19/2015 12:00:00 AM	8/19/2015 8:55 AM
Contacts	Authorizing Official	Update		HOOPES, JOHN CEO 2085472780	HOOPES, JOHN CEO 2085472780	9/8/2014 7:46 AM
Contacts	Primary Contact	Update		Cutler, Kenna Pharmacy Manager 2085472767	HOOPES, JOHN CEO 2085472780	9/8/2014 7:46 AM
Details	Last Recertification Date	Update		8/23/2013 5:28:36 PM	8/29/2014 12:00:00 AM	8/29/2014 8:08 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/23/2013 5:28:36 PM	8/23/2013 5:28 PM
Addresses	Shipping Address	Insert			CARIBOU MEMORIAL HOSPITAL PHARMACY 300 SOUTH 3RD WEST SODA SPRINGS, ID 83276	4/22/2013 5:02 PM
Contacts	Authorizing Official	Insert			HOOPES, JOHN CEO 2085472780	4/19/2013 5:32 PM
Contacts	Primary Contact	Update		KUNZ, BRENDA SNF FINANCIAL COORDINATOR 2085470707	Cutler, Kenna Pharmacy Manager 2085472767	5/16/2012 8:22 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/16/2012 8:22 AM
Contacts	Primary Contact	Insert			KUNZ, BRENDA SNF FINANCIAL COORDINATOR 2085470707	1/31/2011 10:07 AM
Details	Last Recertification Date	Insert				1/31/2011 10:07 AM
Details	Grant Number	Insert				1/31/2011 10:07 AM
Details	340B ID	Insert			CAH131309-00	1/31/2011 10:07 AM
Details	Is Authorizing Official EHB Data	Insert				1/31/2011 10:07 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/31/2011 10:07 AM
Details	Medicare Provider Number	Insert			131309	1/31/2011 10:07 AM
Details	Entity Name	Insert			CARIBOU MEMORIAL HOSPITAL	1/31/2011 10:07 AM
Details	Program Code	Insert			CAH	1/31/2011 10:07 AM
Details	Entity Subname	Insert				1/31/2011 10:07 AM
Dates	Participating Approval Date	Insert			1/31/2011 12:00:00 AM	1/31/2011 10:07 AM
Details	State	Insert			Active	1/31/2011 10:07 AM
Dates	Registration Date	Insert			12/1/2010 12:00:00 AM	1/31/2011 10:07 AM
Dates	Signed By Date	Insert			12/1/2010 12:00:00 AM	1/31/2011 10:07 AM
Dates	Start Date	Insert			4/1/2011 12:00:00 AM	1/31/2011 10:07 AM
Terminations	Termination Comments	Insert				1/31/2011 10:07 AM
Terminations	Termination Date	Insert				1/31/2011 10:07 AM
Terminations	Termination Effective Date	Insert				1/31/2011 10:07 AM
Terminations	Termination Reason	Insert				1/31/2011 10:07 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	12/1/2010 1:34 PM
Medicaid Billing	Medicaid: Number	Insert			002863500	12/1/2010 1:34 PM
Medicaid Billing	Medicaid: State	Insert			ID	12/1/2010 1:34 PM
Medicaid Billing	NPI: Number	Insert			1184752347	12/1/2010 1:34 PM