Covered Entity Details

DSH130007Y Saint Alphonsus Regional Medical Center (Active) - information as of 4/25/2025 6:31:40 PM

Main Details

Name

Saint Alphonsus Regional Medical Center

Subdivision Name

SAMG Heart Care Boise Moreau

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH130007Y

Medicare Provider Number

130007

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2013

Participating Start Date

4/1/2013

Participating Approval Date

3/28/2013

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Saint Alphonsus Health System
Lannie Checketts, RHM CFO Idaho Oregon Region
(208) 367-7347

Primary Contact

Trinity Health
Carisa Ann McGehee, 340B Analyst
(208) 367-2087

Addresses

Street Address

6140 W. Curtisian Ave., Ste. 200
Boise, ID 83704-0107

Billing Address

SAMG Heart Care Boise Moreau
1055 N. Curtis Rd.
Boise, ID 83706

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

SAMG Heart Care Boise Moreau
1055 N. Curtis Rd.
Boise, ID 83706

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
DSH130007A	Child	DSH	Saint Alphonsus Regional Medical Center	Saint Alphonsus Cancer Center	1055 N. Curtis Rd	Boise	ID	Active
DSH130007AA	Child	DSH	Saint Alphonsus Regional Medical Center	SAMGP Heart Care Moreau 102	6140 W Curtisian Ste 102	Boise	ID	Active
DSH130007AE	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG General Surgery and Bariatrics	1072 N Liberty Street Suite 300	Boise	ID	Active
DSH130007AL	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Maternal Fetal Medicine	900 N. Liberty Ste. 206	Boise	ID	Terminated
DSH130007AM	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Neurology Mulvaney	1072 N. Liberty St., Ste. 303	Boise	ID	Active
DSH130007AN	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Neurosurgery 503	901 N Curtis Rd Ste 503	Boise	ID	Active
DSH130007AQ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Neurosurgery Mulvaney	1072 N. Liberty St., Ste. 303	Boise	ID	Active
DSH130007AS	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Coughlin Clinic	901 N. Curtis Rd., Ste. 501	Boise	ID	Terminated
DSH130007AT	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Coughlin Clinic Boise	1075 N Curtis Rd Ste 300	Boise	ID	Active
DSH130007AV	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Joint Center of Excellence	6165 W Emerald St	Boise	ID	Active
DSH130007AX	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Orthopedic Spine Surgery	1075 N Curtis Rd Suite 101	Boise	ID	Terminated
DSH130007AZ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Orthopedics Meridian	3025 W Cherry Lane	Meridian	ID	Terminated
DSH130007B	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG MHP Family Medicine	3025 W Cherry Lane Ste B	Meridian	ID	Active
DSH130007BD	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Pulmonary And Sleep Boise	1075 N Curtis Ste 200	Boise	ID	Active
DSH130007BE	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Trauma Services 415	999 N. Curtis Rd., Ste. 415	Boise	ID	Active
DSH130007BF	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Vascular Services	1075 N Curtis Rd Ste 101	Boise	ID	Active
DSH130007BH	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG W Emerald Family Medicine	6051 W Emerald St	Boise	ID	Active
DSH130007BJ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG W Emerald Urgent Care	6051 W Emerald	Boise	ID	Active
DSH130007BK	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Global Health Family Medicine	6533 W Emerald St	Boise	ID	Active
DSH130007BL	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG McMillan Family Medicine	12273 W. McMillan Rd	Boise	ID	Active
DSH130007BM	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG McMillan Internal Medicine	12273 W. McMillan Rd	Boise	ID	Terminated
DSH130007BN	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Dallan Woods Family Medicine	214 S. Midland Blvd.	Nampa	ID	Terminated
DSH130007BP	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Garrity Campus Family Med	1150 N. Sister Catherine Way	Nampa	ID	Active
DSH130007BQ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Garrity Campus Urgent Care	1150 N. Sister Catherine Way	Nampa	ID	Active
DSH130007BR	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Glycemic Boise	1000 N. Curtis Rd., Ste. 305	Boise	ID	Active
DSH130007BS	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Breast And Gen Surg Liberty	900 N Liberty St. Ste. 101	Boise	ID	Active
DSH130007BT	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Wound And Hyperbaric NHP	4400 E. Flamingo	Nampa	ID	Terminated
DSH130007BU	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Coughlin Clinic Dallan Woods	214 S. Midland Blvd.	Nampa	ID	Terminated
DSH130007BV	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Orthopedics Garrity MOB	4424 E. Flamingo Ave Ste 110	Nampa	ID	Terminated
DSH130007BW	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Behavioral Health	131 N. Allumbaugh	Boise	ID	Terminated
DSH130007BX	Child	DSH	Saint Alphonsus Regional Medical Center	SARMC Breast Care Center	6200 W. Emerald St.	Boise	ID	Active
DSH130007BY	Child	DSH	Saint Alphonsus Regional Medical Center	SARMC EHP ER	323 Riverside Drive	Eagle	ID	Active
DSH130007BZ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Orthopedics Dallan Woods / SAMG Orthopedics Dallan Woods	214 S Midland Blvd	Nampa	ID	Terminated
DSH130007C	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG MHP Internal Medicine	3025 W. Cherry Lane Ste. B	Meridian	ID	Terminated
DSH130007CA	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG ENT Nampa	4400 E Flamingo Ave	Nampa	ID	Terminated
DSH130007CB	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Hearing and Balance Boise	6094 W Emerald St	BOISE	ID	Active
DSH130007CC	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Glycemic 12th Avenue	1510 12th Ave Rd Ste 200	Nampa	ID	Active
DSH130007CD	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Heart Care Garrity MOB	4424 E Flamingo Ave Ste 300	NAMPA	ID	Terminated
DSH130007CE	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG MHP Sleep Medicine	3025 W Cherry Lane STE 204	Meridian	ID	Active
DSH130007CF	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Sleep Medicine Caldwell 430	1906 Fairview Ave Ste 430	Caldwell	ID	Active
DSH130007CG	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Sports Medicine 901	901 N Curtis Ste 501	Boise	ID	Terminated
DSH130007CH	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG OB GYN EHP	323E RIVERSIDE DR 224	EAGLE	ID	Terminated
DSH130007CJ	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Sports Medicine MHP	3025 Cherry Lane	Meridian	ID	Terminated
DSH130007CK	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Sports Medicine YMCA	5959 N Discovery Place	Boise	ID	Terminated
DSH130007CL	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Kuna Family Medicine	757 E Wythe Creek Ct STE 100	Kuna	ID	Active
DSH130007CN	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Heart Care Caldwell 430	1906 Fairview Ave Ste 430	Caldwell	ID	Terminated
DSH130007CP	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG GLYCEMIC CHERRY LANE	3250 W CHERRY LANE	MERDIAN	ID	Active
DSH130007CQ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Comp Breast Surgery Nampa	4400 E Flamingo	Nampa	ID	Terminated
DSH130007CR	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Neurology Caldwell 430	1906 Fairview Ave Ste 430	Caldwell	ID	Terminated
DSH130007CS	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Orthopedics Emerald	6500 W Emerald St	Boise	ID	Terminated
DSH130007CT	Child	DSH	Saint Alphonsus Regional Medical Center	Saint Alphonsus Spine Care	1055 N. CURTIS RD	Boise	ID	Terminated
DSH130007CU	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG PULMONARY AND SLEEP NAMPA	401 E HAWAII AVE	NAMPA	ID	Terminated
DSH130007CV	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Pulmonary Caldwell 430	1906 Fairview Ave Ste 430	Caldwell	ID	Terminated
DSH130007CW	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Orthopedics Hartman	1075 N Curtis Rd Ste 300	Boise	ID	Terminated
DSH130007CX	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Vascular Services Caldwell	1906 Fairview Ave Ste 430	Caldwell	ID	Terminated
DSH130007CY	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Vascular Services Nampa	4400 E Flamingo Ave	Nampa	ID	Terminated
DSH130007CZ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG W Chinden Family Medicine Clinic	3217 W Bavaria	Eagle	ID	Active
DSH130007D	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG MHP Urgent Care	3025 W. Cherry Lane Ste. B	Meridian	ID	Active
DSH130007DA	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Clinic At Eagle	600 E State St Ste 200	Eagle	ID	Terminated
DSH130007DB	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Cherry Lane Family Clinic	3250 W Cherry Lane	Meridian	ID	Terminated
DSH130007DC	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Comp Pain Spine Nampa	1524 12th Ave Rd	Nampa	ID	Terminated
DSH130007DD	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Neurology Nampa / Neurology	401 E Hawaii Ave	Nampa	ID	Terminated
DSH130007DE	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Acute Pain Clinic / Pain Services	1055 N Curtis Rd	Boise	ID	Terminated
DSH130007DF	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG General Surgery Mulvaney	1072 N Liberty St Ste 201	Boise	ID	Active
DSH130007DG	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG / Plastic Reconstructive Surgery	900 N Liberty St Ste 101	Boise	ID	Active
DSH130007DH	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Gyn Onc Liberty / Gynecological Oncology	900 N Liberty St Ste 101	Boise	ID	Active
DSH130007DJ	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Boise Pediatrics Kuna / Pediatrics	757 E Wythe Creek Ct	Kuna	ID	Terminated
DSH130007DK	Child	DSH	ST. ALPHONSUS REGIONAL MED CENTER	SAMG Sports Medicine Emerald / Sports Medicine	6500 W Emerald St	Boise	ID	Terminated
DSH130007DL	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG W Chinden Urgent Care	3217 W Bavaria	Boise	ID	Terminated
DSH130007DM	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Boise Bench Urgent Care	1880 W Judith Ln	Boise	ID	Terminated
DSH130007DN	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG BHP / Family Medicine	2141 E PARKCENTER BLVD	BOISE	ID	Active
DSH130007DP	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Heart Care Nampa	1524 12th Ave Rd	Nampa	ID	Terminated
DSH130007DQ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG HEART CARE EAGLE	323 E RIVERSIDE DR STE 224	EAGLE	ID	Active
DSH130007DR	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Trauma and Fracture Clinic	6165 W Emerald St	Boise	ID	Active
DSH130007DS	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Lake Hazel Family Medicine	10583 W Lake Hazel Rd	Boise	ID	Active
DSH130007DT	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Kuna / Urgent Care	757 E Wythe Creek Ct STE 100	Kuna	ID	Active
DSH130007DU	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Cancer Pain Clinic	1055 N Curtis Rd	Boise	ID	Terminated
DSH130007DV	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG KARCHER / Pediatrics	11035 KARCHER RD	NAMPA	ID	Terminated
DSH130007DW	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG KARCHER / Family Medicine	11035 KARCHER RD	NAMPA	ID	Active
DSH130007DX	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG 12th Avenue Family Medicine	1510 12th Ave Rd STE 200	NAMPA	ID	Active
DSH130007DY	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG ORTHOPEDICS EHP / ORTHOPEDICS	323 E RIVERSIDE DR STE 224	EAGLE	ID	Terminated
DSH130007DZ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG BHP URGENT CARE - Urgent Care	2141 E PARKCENTER BLVD	BOISE	ID	Active
DSH130007EA	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Coughlin Clinic 12th Avenue	1510 12th Ave Rd STE 200	NAMPA	ID	Terminated
DSH130007EB	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG KARCHER URGENT CARE - Urgent Care	11035 KARCHER RD	NAMPA	ID	Active
DSH130007EC	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG LAKE HAZEL URGENT CARE - Urgent Care	10583 W LAKE HAZEL RD	BOISE	ID	Active
DSH130007ED	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Metabolic and Bariatric Center - Bariatric care	6140 W Curtisian Ave Ste 100	Boise	ID	Terminated
DSH130007EE	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Garrity Campus Pediatric Clinic - Pediatrics	4400 E Flamingo Ave	Nampa	ID	Active
DSH130007EF	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG OBGYN GLOBAL HEALTH	6533 W EMERALD ST	BOISE	ID	Active
DSH130007EG	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG BEHAVIORAL HEALTH MHP - BEHAVIORAL HEALTH	SAMG BEHAVIORAL HEALTH MHP	MERIDIAN	ID	Terminated
DSH130007EH	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Boise Bench FAMILY MEDICINE	1880 W Judith Ln	BOISE	ID	Terminated
DSH130007EJ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG GLYCEMIC CALDWELL - GLYCEMIC	1906 FAIRVIEW AVE STE 430	CALDWELL	ID	Active
DSH130007EK	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG SPORTS MEDICINE JCOE - SPORTS MEDICINE	6165 W EMERALD ST	BOISE	ID	Active
DSH130007EL	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG W CHINDEN PEDIATRICS - PEDIATRICS	3217 W BAVARIA	EAGLE	ID	Active
DSH130007EM	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG STAR FAMILY MEDICINE - Family Medicine	10717 W STATE ST	STAR	ID	Active
DSH130007EN	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG SPORTS MEDICINE BOWN - Sports Medicine	2141 E PARKCENTER BLVD	BOISE	ID	Terminated
DSH130007EP	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG COPPER POINT FAMILY MEDICINE - Family Med	3041 E COPPER POINT DR	MERIDIAN	ID	Terminated
DSH130007EQ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG EXTENSIVISTS - Extensivists- geriatric	5966 W CURTISIAN AVE	BOISE	ID	Active
DSH130007ER	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG PALLIATIVE CLINIC BOISE - Palliative care	5966 W CURTISIAN AVE	BOISE	ID	Terminated
DSH130007ES	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG GERIATRIC PALLIATIVE CURTISIAN	5966 W CURTISIAN AVE	BOISE	ID	Active
DSH130007ET	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Star Urgent Care - Urgent Care	10717 W State St	Star	ID	Active
DSH130007EU	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG OB GYN Emerald - Obstetrics and gynecology	6533 W Emerald St	Boise	ID	Terminated
DSH130007EV	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Orthopedic Urgent Care - Orthopedic Urgent Care	6051 W Emerald St	Boise	ID	Active
DSH130007EW	Child	DSH	Saint Alphonsus Regional Medical Center	SAMGP Cardiothoracic & Heart Care Moreau 100	6140 W Curtisian Ave Ste 100	Boise	ID	Active
DSH130007EX	Child	DSH	Saint Alphonsus Regional Medical Center	SAMGP Urology Caldwell 430 - Urology Clinic	1906 Fairview Ave Ste 430	Caldwell	ID	ToBeTerminated
DSH130007EY	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Structural Heart Moreau - Cardiology	6140 W Curtisian Ave	Boise	ID	Active
DSH130007EZ	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Heart Failure Moreau - Cardiology	6140 W Curtisian Ave	Boise	ID	Active
DSH130007F	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Overland Family Medicine	10255 W. Overland Rd.	Boise	ID	Active
DSH130007FA	Child	DSH	Saint Alphonsus Regional Medical Center	AntiCoagulation Clinic Boise - Anticoagulation	999 N Curtis Rd	Boise	ID	Active
DSH130007FB	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Care Clinic Global Health - Family	6533 W Emerald St	Boise	ID	ToBeTerminated
DSH130007FC	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Radiation Oncology - Oncology	1055 N Curtis Rd	Boise	ID	Active
DSH130007FD	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Gyn Onc Caldwell - Gyn Onc	1906 Fairview Ave	Caldwell	ID	Active
DSH130007FE	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG General Surgery Caldwell - Surgery	1906 Fairview Ave	Caldwell	ID	Terminated
DSH130007FF	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Geriatrics Clinic 12th Ave - Geriatrics	1510 12th Ave Rd	Nampa	ID	Active
DSH130007FG	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Geriatrics EHP - Geriatrics	323 E Riverside Dr	Eagle	ID	Active
DSH130007G	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Shoreline Family Medicine	1673 W. Shoreline Dr., Ste. 120	Boise	ID	Terminated
DSH130007L	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Curtisian Internal Medicine and Geriatrics	5966 W. Curtisian Ave.	Boise	ID	Active
DSH130007P	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG EHP Family Practice	323 Riverside Drive Ste. 224	Eagle	ID	Terminated
DSH130007Q	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG EHP Internal Medicine	323 Riverside Drive Ste. 224	Eagle	ID	Active
DSH130007R	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG EHP Pediatrics	323 Riverside Drive Ste. 224	Eagle	ID	Terminated
DSH130007T	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG OBGYN Mulvaney	1072 N. Liberty, Suite 100	Boise	ID	Active
DSH130007W	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG BOISE PEDIATRICS MULVANEY	1072 N LIBERTY STREET	Boise	ID	Active
DSH130007X	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Heart Care Ste. 300	6140 W. Curtisian Ave. Ste. 300	Boise	ID	Active
DSH130007Y	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Heart Care Boise Moreau	6140 W. Curtisian Ave., Ste. 200	Boise	ID	Active
DSH130007Z	Child	DSH	Saint Alphonsus Regional Medical Center	SAMG Heart Care Meridian	3025 W. Cherry Lane Ste. 205	Meridian	ID	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/24/2023 5:50:54 PM	8/20/2024 2:25:47 PM	8/20/2024 2:25 PM
Details	Last Recertification Date	Update	Recertification	9/14/2022 12:32:19 PM	8/24/2023 5:50:54 PM	8/24/2023 5:50 PM
Details	Last Recertification Date	Update	Recertification	9/13/2021 10:33:41 AM	9/14/2022 12:32:19 PM	9/14/2022 12:32 PM
Details	Last Recertification Date	Update	Recertification	9/2/2020 3:16:57 PM	9/13/2021 10:33:41 AM	9/13/2021 10:33 AM
Details	Last Recertification Date	Update	Recertification	9/4/2019 2:58:22 PM	9/2/2020 3:16:57 PM	9/2/2020 3:16 PM
Details	Last Recertification Date	Update	Recertification	8/30/2018 1:02:45 PM	9/4/2019 2:58:22 PM	9/4/2019 2:58 PM
Contacts	Primary Contact	Update	Change Request	Phillips, Mark AVP Prof Services/Director SAHS Pharmacy Saint Alphonsus Health System 2083674943	McGehee, Carisa Ann 340B Analyst Trinity Health 2083672087	1/21/2019 3:43 PM
Details	Last Recertification Date	Update	Recertification	11/3/2017 12:34:55 PM	8/30/2018 1:02:45 PM	8/30/2018 1:02 PM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/3/2017 12:34:55 PM	11/3/2017 12:34 PM
Contacts	Primary Contact	Update	New Registration	Phillips, Mark AVP Prof Services/Director SAHS Pharmacy 2083674943	Phillips, Mark AVP Prof Services/Director SAHS Pharmacy Saint Alphonsus Health System 2083674943	10/13/2017 9:51 AM
Contacts	Authorizing Official	Update		Checketts, Lannie RHM CFO Idaho Oregon Region 2083677347	Checketts, Lannie RHM CFO Idaho Oregon Region Saint Alphonsus Health System 2083677347	10/11/2017 12:18 PM
Contacts	Authorizing Official	Insert			Checketts, Lannie RHM CFO Idaho Oregon Region 2083677347	8/4/2017 10:49 AM
Contacts	Primary Contact	Insert			Phillips, Mark AVP Prof Services/Director SAHS Pharmacy 2083674943	8/4/2017 10:49 AM
Contacts	Signed By	Insert			Phillips, Mark Director of Pharmacy 2083674943	8/1/2017 2:13 PM
Addresses	Main Address	Insert			6140 W. Curtisian Ave., Ste. 200 Boise, ID 83704-0107	7/21/2017 6:21 PM
Addresses	Billing Address	Insert			SAMG Heart Care Boise Moreau 1055 N. Curtis Rd. Boise, ID 83706	7/21/2017 6:21 PM
Addresses	Shipping Address	Insert			SAMG Heart Care Boise Moreau 1055 N. Curtis Rd. Boise, ID 83706	7/21/2017 6:21 PM
Details	Last Recertification Date	Update		9/3/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 1:33 PM
Details	Last Recertification Date	Update		8/13/2014 12:00:00 AM	9/3/2015 12:00:00 AM	9/3/2015 12:29 PM
Details	Last Recertification Date	Update		9/11/2013 12:00:00 AM	8/13/2014 12:00:00 AM	8/13/2014 2:13 PM
Details	Last Recertification Date	Update		9/11/2013 12:58:27 PM	9/11/2013 12:00:00 AM	7/2/2014 11:45 PM
Details	Last Recertification Date	Update			9/11/2013 12:58:27 PM	9/11/2013 12:58 PM
Details	340B ID	Update		ISDMDSH130007Y	DSH130007Y	3/28/2013 2:09 PM
Dates	Participating Approval Date	Update			3/28/2013 12:00:00 AM	3/28/2013 2:09 PM
Details	State	Update		Pending	Active	3/28/2013 2:09 PM
Dates	Start Date	Update			4/1/2013 12:00:00 AM	3/28/2013 2:09 PM
Details	340B ID	Update		DELETE_JT130007_23	ISDMDSH130007Y	3/26/2013 2:00 PM
Details	State	Update		Rejected	Pending	3/26/2013 2:00 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DELETE_JT130007_23	3/8/2013 11:31 AM
Details	State	Update		Pending	Rejected	3/8/2013 11:31 AM
Details	Last Recertification Date	Insert				1/15/2013 12:01 PM
Details	Grant Number	Insert				1/15/2013 12:01 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	1/15/2013 12:01 PM
Details	Is Authorizing Official EHB Data	Insert				1/15/2013 12:01 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/15/2013 12:01 PM
Details	Medicare Provider Number	Insert			130007	1/15/2013 12:01 PM
Details	Entity Name	Insert			Saint Alphonsus Regional Medical Center	1/15/2013 12:01 PM
Details	Program Code	Insert			DSH	1/15/2013 12:01 PM
Details	Entity Subname	Insert			SAMG Heart Care Boise Moreau	1/15/2013 12:01 PM
Dates	Participating Approval Date	Insert				1/15/2013 12:01 PM
Details	State	Insert			Pending	1/15/2013 12:01 PM
Dates	Registration Date	Insert			1/15/2013 12:00:00 AM	1/15/2013 12:01 PM
Dates	Signed By Date	Insert			1/15/2013 12:00:00 AM	1/15/2013 12:01 PM
Dates	Start Date	Insert				1/15/2013 12:01 PM
Terminations	Termination Comments	Insert				1/15/2013 12:01 PM
Terminations	Termination Date	Insert				1/15/2013 12:01 PM
Terminations	Termination Effective Date	Insert				1/15/2013 12:01 PM
Terminations	Termination Reason	Insert				1/15/2013 12:01 PM