Covered Entity Details

DSH130049H KOOTENAI MEDICAL CENTER (Terminated) - information as of 6/26/2025 12:29:22 AM

Main Details

Name

KOOTENAI MEDICAL CENTER

Subdivision Name

KOOTENAI FAMILY & INTERNAL MEDICINE

Type

Disproportionate Share Hospital

Rural

340B ID

DSH130049H

Medicare Provider Number

130049

Outpatient Facility Provider Number

130049

Additional Details

Current Program Status

Terminated

Registration Date

7/14/2014

Participating Start Date

10/1/2014

Participating Approval Date

9/10/2014

Last Recertification Date

Termination Date
Termination Reason

7/1/2015
Loss of qualifying grant/support

Contacts

Authorizing Official

Kootenai Health
Kim Webb, CFO
(208) 625-4001

Primary Contact

Jeremy S. Evans, Vice President
(208) 625-4002

Addresses

Street Address

925 E POLSTON AVENUE
POST FALLS, ID 83854-9049

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
DSH130049AA	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Neurology	700 Ironwood Dr. #158	Coeur d'Alene	ID	ToBeTerminated
DSH130049AB	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE	1300 E MULLAN AVE #1300	POST FALLS	ID	ToBeTerminated
DSH130049AC	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC PLASTIC AND RECONSTRUCTIVE SURGERY	980 W. Ironwood Drive, Suite 01	Coeur d'Alene	ID	ToBeTerminated
DSH130049AD	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI HEART CLINICS NORTHWEST	700 W IRONWOOD DR #320	COEUR D ALENE	ID	ToBeTerminated
DSH130049AE	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC PSYCHIATRY	2199 Ironwood Center Drive	Coeur d'Alene	ID	Terminated
DSH130049AF	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEART CLINICS NORTHWEST	423 N 3RD AVE #355	SANDPOINT	ID	Terminated
DSH130049AG	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEART CLINICS NORTHWEST	122 W 7TH AVE STE 310	SPOKANE	WA	Terminated
DSH130049AH	Child	DSH	KOOTENAI HOSPITAL DISTRICT	MCGRANE CENTER FOR REHABILITATION	2003 Kootenai Health Way	Coeur d'Alene	ID	Terminated
DSH130049AJ	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI OUTPATIENT IMAGING	1300 East Mullan Avenue STE 700	Post Falls	ID	Terminated
DSH130049AK	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI OUTPATIENT IMAGING	1919 Lincoln Way STE #111	Coeur d'Alene	ID	Terminated
DSH130049AL	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI OUTPATIENT IMAGING	700 West Ironwood, STE 175	Coeur d'Alene	ID	Terminated
DSH130049AM	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEART CLINICS NORTHWEST	212 E CENTRAL STE #335	SPOKANE	WA	Terminated
DSH130049AN	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI HEALTH - ADVANCED HEART DISEASE MANAGEMENT CLINIC/ELECTROPHYSIOLOGY	700 W IRONWOOD DRIVE, SUITE 350	Coeur d' Alene	ID	ToBeTerminated
DSH130049AP	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI HEART CLINICS NORTHWEST	1300 E MULLAN AVE 900	POST FALLS	ID	ToBeTerminated
DSH130049AQ	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEART CLINICS NORTHWEST	13102 E MISSION AVE	SPOKANE VALLEY	WA	Terminated
DSH130049AR	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC VASCULARY SURGERY	700 IRONWOOD DR SUITE 350	COEUR D ALENE	ID	ToBeTerminated
DSH130049AS	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC - SLEEP MEDICINE	700 Ironwood Drive	COEUR D'ALENE	ID	ToBeTerminated
DSH130049AT	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC - ORTHOPEDICS POST FALLS	1296 E Polston Ave Ste C	Post Falls	ID	ToBeTerminated
DSH130049AU	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Cancer Services	700 W Ironwood Dr., Suite #230	Coeur d' Alene	ID	ToBeTerminated
DSH130049AV	Child	DSH	KOOTENAI HOSPITAL DISTRICT	Kootenai Clinic Neurosurgery	700 W Ironwood Dr Ste 258	Coeur d' Alene	ID	Terminated
DSH130049AW	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic - Orthopedics	2177 W. Ironwood Center Drive	Couer d' Alene	ID	ToBeTerminated
DSH130049AX	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Nephrology - Nephrology	700 W Ironwood Dr	Coeur d'Alene	ID	ToBeTerminated
DSH130049AY	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Wound Care - Wound Care, Infectious Disease	2120 W. Ironwood Center Dr.	Coeur d'Alene	ID	ToBeTerminated
DSH130049AZ	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC LUNG & ASTHMA - LUNG & ASTHMA	706 W IRONWOOD DR	COEUR D'ALENE	ID	ToBeTerminated
DSH130049B	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC CANCER SERVICES	1440 E MULLAN AVE	POST FALLS	ID	ToBeTerminated
DSH130049BA	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE CDA IRONWOOD - FAMILY MEDICINE	914 W IRONWOOD DR	COEUR D'ALENE	ID	ToBeTerminated
DSH130049BB	Child	DSH	KOOTENAI HEALTH INC	ANTICOAGULATION CLINIC - ANTICOAG CLINIC	700 IRONWOOD DRIVE	COEUR D'ALENE	ID	ToBeTerminated
DSH130049C	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC CANCER SERVICES	700 W IRONWOOD DR #130	COEUR D ALENE	ID	ToBeTerminated
DSH130049D	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC CANCER SERVICES	520 N THIRD AVE	SANDPOINT	ID	ToBeTerminated
DSH130049E	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC DIABETES AND ENDOCRINOLOGY	1919 LINCOLN WAY #211	COEUR D'ALENE	ID	ToBeTerminated
DSH130049F	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC EAR NOSE THROAT & ALLERGY	420 N 2ND AVE STE #300	SANDPOINT	ID	Terminated
DSH130049G	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC EAR NOSE THROAT & ALLERGY	700 W IRONWOOD DR STE 278	COEUR D ALENE	ID	ToBeTerminated
DSH130049H	Child	DSH	KOOTENAI MEDICAL CENTER	KOOTENAI FAMILY & INTERNAL MEDICINE	925 E POLSTON AVENUE	POST FALLS	ID	Terminated
DSH130049J	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE	1701 LINCOLN WAY	COEUR D ALENE	ID	ToBeTerminated
DSH130049K	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE	566 W PRAIRIE AVENUE	COEUR D ALENE	ID	ToBeTerminated
DSH130049L	Child	DSH	KOOTENAI MEDICAL CENTER	KOOTENAI CLINIC FAMILY MEDICINE	16760 N HWY 41	RATHDRUM	ID	Terminated
DSH130049M	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE CDA RESIDENCY	1919 LINCOLN WAY #315	COEUR D'ALENE	ID	ToBeTerminated
DSH130049N	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Gastroenterology	1919 Lincoln Way #415	Coeur d'Alene	ID	ToBeTerminated
DSH130049P	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Gastroenterology & Endoscopy	1919 Lincoln Way #416	Coeur d'Alene	ID	ToBeTerminated
DSH130049Q	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Hand Surgery	2121 W. Ironwood Center Dr.	Coeur d'Alene	ID	ToBeTerminated
DSH130049R	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC OBSTETRICS & GYNECOLOGY	1300 E MULLAN AVE STE 500	POST FALLS	ID	ToBeTerminated
DSH130049S	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC OBSTETRICS & GYNECOLOGY	980 W IRONWOOD DR STE 306	COEUR D ALENE	ID	ToBeTerminated
DSH130049T	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC INTERNAL MEDICINE	1300 E MULLAN AVE STE 1600	POST FALLS	ID	ToBeTerminated
DSH130049U	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC RHEUMATOLOGY	700 W Ironwood Dr, STE 275	Coeur d'Alene	ID	ToBeTerminated
DSH130049V	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC GENERAL SURGERY	700 W IRONWOOD DR STE 341	COEUR D ALENE	ID	ToBeTerminated
DSH130049W	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC INTERNAL MEDICINE	1919 LINCOLN WAY #110	COEUR D'ALENE	ID	ToBeTerminated
DSH130049X	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC INTERNAL MEDICINE	1701 LINCOLN WAY	COEUR D ALENE	ID	Terminated
DSH130049Y	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC INTERNAL MEDICINE	920 W IRONWOOD DR STE 201	COEUR D ALENE	ID	Terminated
DSH130049Z	Child	DSH	KOOTENAI MEDICAL CENTER	KOOTENAI CLINIC FAMILY MEDICINE	1300 E MULLAN AVE STE 1600	COEUR D ALENE	ID	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Adams, John Controller Kootenai Health 2086254360	Webb, Kim CFO Kootenai Health 2086254001	4/27/2018 1:29 PM
Contacts	Authorizing Official	Update		Adams, John Controller 2086254360	Adams, John Controller Kootenai Health 2086254360	9/21/2017 9:11 PM
Contacts	Authorizing Official	Update		Simon, Joan Chief Nursing Officer 2086254002	Adams, John Controller 2086254360	9/11/2017 3:29 PM
Contacts	Authorizing Official	Insert			Simon, Joan Chief Nursing Officer 2086254002	7/28/2017 6:31 PM
Contacts	Primary Contact	Insert			Evans, Jeremy S. Vice President 2086254002	7/28/2017 6:31 PM
Contacts	Signed By	Insert			Evans, Jeremy S. Vice President 2086254002	7/28/2017 6:31 PM
Addresses	Main Address	Insert			925 E POLSTON AVENUE POST FALLS, ID 83854-9049	4/14/2015 8:13 AM
Dates	Last Date That 340B Drugs Purchased	Update			4/3/2015 12:00:00 AM	4/14/2015 8:12 AM
Details	State	Update		Active	Terminated	4/14/2015 8:12 AM
Terminations	Termination Comments	Update			This clinic no longer services Kootenai Health patients effective 6 April 15. Providers serving in this clinic have been removed from Kootenai's list of eligible 340b providers.	4/14/2015 8:12 AM
Terminations	Termination Date	Update			7/1/2015 12:00:00 AM	4/14/2015 8:12 AM
Terminations	Termination Effective Date	Update			4/6/2015 12:00:00 AM	4/14/2015 8:12 AM
Terminations	Termination Reason	Update			Loss of qualifying grant/support	4/14/2015 8:12 AM
Dates	Participating Approval Date	Update			9/10/2014 12:00:00 AM	9/10/2014 11:18 AM
Details	State	Update		Pending	Active	9/10/2014 11:18 AM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	9/10/2014 11:18 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_45673	DSH130049H	9/9/2014 6:36 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_45673	7/14/2014 5:07 PM
Details	Last Recertification Date	Insert				7/14/2014 5:07 PM
Details	Grant Number	Insert				7/14/2014 5:07 PM
Details	340B ID	Insert				7/14/2014 5:07 PM
Details	Is Authorizing Official EHB Data	Insert				7/14/2014 5:07 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/14/2014 5:07 PM
Details	Medicare Provider Number	Insert			130049	7/14/2014 5:07 PM
Details	Entity Name	Insert			KOOTENAI MEDICAL CENTER	7/14/2014 5:07 PM
Details	Program Code	Insert			DSH	7/14/2014 5:07 PM
Details	Entity Subname	Insert			KOOTENAI FAMILY & INTERNAL MEDICINE	7/14/2014 5:07 PM
Dates	Participating Approval Date	Insert				7/14/2014 5:07 PM
Details	State	Insert			Pending	7/14/2014 5:07 PM
Dates	Registration Date	Insert			7/14/2014 12:00:00 AM	7/14/2014 5:07 PM
Dates	Signed By Date	Insert			7/14/2014 12:00:00 AM	7/14/2014 5:07 PM
Dates	Start Date	Insert				7/14/2014 5:07 PM
Terminations	Termination Comments	Insert				7/14/2014 5:07 PM
Terminations	Termination Date	Insert				7/14/2014 5:07 PM
Terminations	Termination Effective Date	Insert				7/14/2014 5:07 PM
Terminations	Termination Reason	Insert				7/14/2014 5:07 PM