Covered Entity Details

CAH131313-01 Teton Valley Health Care, Inc. dba Teton Valley Hospital (Active) - information as of 5/20/2025 12:44:11 AM

Main Details

Name

Teton Valley Health Care, Inc. dba Teton Valley Hospital

Subdivision Name

Driggs Medical Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH131313-01

Medicare Provider Number

131313

Outpatient Facility Provider Number

138511

Additional Details

Current Program Status

Active

Registration Date

4/12/2013

Participating Start Date

7/1/2013

Participating Approval Date

4/18/2013

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Teton Valley Health
Troy Christensen, CEO
(208) 354-6340

Primary Contact

Teton Valley health
Cassidy Howarth, DOP
(208) 354-6316

Addresses

Street Address

283 North First East Street
Driggs, ID 83422

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

Same as Street Address

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
CAH131313-01	Child	CAH	Teton Valley Health Care, Inc. dba Teton Valley Hospital	Driggs Medical Clinic	283 North First East Street	Driggs	ID	Active
CAH131313-02	Child	CAH	Teton Valley Health Care, Inc. dba Teton Valley Hospital	Victor Medical Clinic	83 North Main Street	Victor	ID	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/28/2023 12:36:30 PM	8/12/2024 12:48:19 PM	8/12/2024 12:48 PM
Contacts	Authorizing Official	Update	Change Request	Levanger, Nathan Interim CEO Teton Valley Health 2083546355	Christensen, Troy CEO Teton Valley Health 2083546340	10/27/2023 11:39 AM
Details	Last Recertification Date	Update	Recertification	8/27/2022 5:14:27 PM	8/28/2023 12:36:30 PM	8/28/2023 12:36 PM
Contacts	Primary Contact	Update	Change Request	Berry, Brad DOP Teton Valley Health 2083546316	Howarth, Cassidy DOP Teton Valley health 2083546316	7/17/2023 11:55 AM
Contacts	Authorizing Official	Update	Change Request	Gnagey, Keith CEO Teton Valley Health Care, Inc. 2083546355	Levanger, Nathan Interim CEO Teton Valley Health 2083546355	7/14/2023 7:38 AM
Details	Last Recertification Date	Update	Recertification	8/25/2021 2:52:43 PM	8/27/2022 5:14:27 PM	8/27/2022 5:14 PM
Contacts	Primary Contact	Update	Change Request	Brandt Correia, Terri Lynne CNO Teton Valley Health 2083546325	Berry, Brad DOP Teton Valley Health 2083546316	3/15/2022 10:08 AM
Details	Last Recertification Date	Update	Recertification	9/10/2020 7:59:32 AM	8/25/2021 2:52:43 PM	8/25/2021 2:52 PM
Contacts	Primary Contact	Update	Recertification	Booker, Angela CNO Teton Valley Health Care, Inc. 2083546325	Brandt Correia, Terri Lynne CNO Teton Valley Health 2083546325	9/10/2020 7:59 AM
Details	Last Recertification Date	Update	Recertification	8/22/2019 12:30:12 PM	9/10/2020 7:59:32 AM	9/10/2020 7:59 AM
Details	Last Recertification Date	Update	Recertification	8/17/2018 3:35:01 PM	8/22/2019 12:30:12 PM	8/22/2019 12:30 PM
Details	Last Recertification Date	Update	Recertification	11/27/2017 11:54:19 AM	8/17/2018 3:35:01 PM	8/17/2018 3:35 PM
Details	Last Recertification Date	Update	Recertification	8/14/2016 12:00:00 AM	11/27/2017 11:54:19 AM	11/27/2017 11:54 AM
Contacts	Authorizing Official	Update		Gnagey, Keith CEO 2083546355	Gnagey, Keith CEO Teton Valley Health Care, Inc. 2083546355	11/2/2017 3:44 PM
Contacts	Signed By	Update		Gnagey, Keith CEO 2083546355	Gnagey, Keith CEO Teton Valley Health Care, Inc. 2083546355	11/2/2017 3:44 PM
Contacts	Primary Contact	Update		Booker, Angela CNO 2083546325	Booker, Angela CNO Teton Valley Health Care, Inc. 2083546325	11/2/2017 2:54 PM
Contacts	Authorizing Official	Insert			Gnagey, Keith CEO 2083546355	8/14/2016 5:50 PM
Contacts	Signed By	Insert			Gnagey, Keith CEO 2083546355	8/14/2016 5:50 PM
Contacts	Primary Contact	Insert			Booker, Angela CNO 2083546325	8/14/2016 5:50 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/14/2016 12:00:00 AM	8/14/2016 5:50 PM
Addresses	Main Address	Insert			283 North First East Street Driggs, ID 83422	8/14/2016 5:50 PM
Details	Last Recertification Date	Update		9/3/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 10:02 PM
Details	Last Recertification Date	Update		8/30/2013 10:50:07 AM	9/3/2014 12:00:00 AM	9/3/2014 2:15 PM
Details	Last Recertification Date	Update			8/30/2013 10:50:07 AM	8/30/2013 10:50 AM
Details	340B ID	Update		ISAPCAH131313-01	CAH131313-01	4/18/2013 3:19 PM
Dates	Participating Approval Date	Update			4/18/2013 12:00:00 AM	4/18/2013 3:19 PM
Details	State	Update		Pending	Active	4/18/2013 3:19 PM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	4/18/2013 3:19 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISAPCAH131313-01	4/18/2013 12:07 PM
Details	Last Recertification Date	Insert				4/12/2013 1:32 PM
Details	Grant Number	Insert				4/12/2013 1:32 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/12/2013 1:32 PM
Details	Is Authorizing Official EHB Data	Insert				4/12/2013 1:32 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/12/2013 1:32 PM
Details	Medicare Provider Number	Insert			131313	4/12/2013 1:32 PM
Details	Entity Name	Insert			Teton Valley Health Care, Inc. dba Teton Valley Hospital	4/12/2013 1:32 PM
Details	Program Code	Insert			CAH	4/12/2013 1:32 PM
Details	Entity Subname	Insert			Driggs Medical Clinic	4/12/2013 1:32 PM
Dates	Participating Approval Date	Insert				4/12/2013 1:32 PM
Details	State	Insert			Pending	4/12/2013 1:32 PM
Dates	Registration Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 1:32 PM
Dates	Signed By Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 1:32 PM
Dates	Start Date	Insert				4/12/2013 1:32 PM
Terminations	Termination Comments	Insert				4/12/2013 1:32 PM
Terminations	Termination Date	Insert				4/12/2013 1:32 PM
Terminations	Termination Effective Date	Insert				4/12/2013 1:32 PM
Terminations	Termination Reason	Insert				4/12/2013 1:32 PM