Covered Entity Details

DSH130013D SAINT ALPHONSUS MEDICAL CENTER-NAMPA (Terminated) - information as of 5/25/2025 1:04:40 AM

Main Details

Name

SAINT ALPHONSUS MEDICAL CENTER-NAMPA

Subdivision Name

Saint Alphonsus Medical Center-Nampa Garrity Campus

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH130013D

Medicare Provider Number

130013

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/15/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/14/2015

Last Recertification Date

9/8/2015

Termination Date
Termination Reason

7/1/2016
Site closure

Contacts

Authorizing Official

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

Primary Contact

Barry Mallard, Director of Pharmacy Services
(208) 463-5365

Addresses

Street Address

4402 E FLAMINGO AVE
NAMPA, ID 83687-9203

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
DSH130013A	Child	DSH	Saint Alphonsus Medical Center Nampa	Caldwell Cancer Care Center	3123 Medical Drive	Caldwell	ID	Terminated
DSH130013B	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER-NAMPA	Nampa Emergency NHP	4402 E FLAMINGO AVE	NAMPA	ID	Terminated
DSH130013C	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER-NAMPA	Nampa NHP Wound/Hyperbaric Service	4402 E FLAMINGO AVE	NAMPA	ID	Terminated
DSH130013D	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER-NAMPA	Saint Alphonsus Medical Center-Nampa Garrity Campus	4402 E FLAMINGO AVE	NAMPA	ID	Terminated
DSH130013E	Child	DSH	Saint Alphonsus Medical Center Nampa	Cancer Care Center SAMC-N	4400 E Flamingo Ave	Nampa	ID	Terminated
DSH130013F	Child	DSH	Saint Alphonsus Medical Center Nampa	Medical Cardiology Observation	4400 E. Flamingo Avenue	Nampa	ID	Terminated
DSH130013G	Child	DSH	Saint Alphonsus Medical Center Nampa	OB Observation	4400 E. Flamingo Avenue	Nampa	ID	Terminated
DSH130013H	Child	DSH	Saint Alphonsus Medical Center Nampa	SAMG General Surgery Garrity - Surgery	4400 E Flamingo Ave Suite 200	Nampa	ID	Terminated
DSH130013J	Child	DSH	Saint Alphonsus Medical Center Nampa	SAMGP Pulmonary Garrity MOB	4424 E Flamingo Ave Suite 210	Nampa	ID	Terminated
DSH130013K	Child	DSH	Saint Alphonsus Medical Center Nampa	Nampa Pain Management - Pain	4424 E Flamingo Ave STE 310	Nampa	ID	Terminated
DSH130013L	Child	DSH	Saint Alphonsus Medical Center Nampa	Saint Alphonsus 12th Avenue ER - Emergency Services	1510 12th Avenue	Nampa	ID	Terminated
DSH130013M	Child	DSH	Saint Alphonsus Medical Center Nampa	SAMG Wound/Hyperbaric at NHP - Wound hyperbaric	4400 E Flamingo	Nampa	ID	Terminated
DSH130013N	Child	DSH	Saint Alphonsus Medical Center Nampa	SAMG ENT Garrity - Ear Nose Throat	4400 E Flamingo St	Nampa	ID	Terminated
DSH130013P	Child	DSH	Saint Alphonsus Medical Center Nampa	SAMG Heart Care MOB Garrity - Heart Care	4424 E Flamingo	Nampa	ID	Terminated
DSH130013Q	Child	DSH	Saint Alphonsus Medical Center Nampa	SAMG Orthopedics- PBB Nampa - Orthopedic	4424 E Flamingo Ave	Nampa	ID	Terminated
DSH130013R	Child	DSH	Saint Alphonsus Medical Center Nampa	SAMG Radiation Oncology Garrity - Oncology	4400 E Flamingo Ave	Nampa	ID	Terminated
DSH130013S	Child	DSH	Saint Alphonsus Medical Center Nampa	SAMG Acute Spine Garrity - Spine Care	4424 E Flamingo Ave	Nampa	ID	Terminated
DSH130013T	Child	DSH	Saint Alphonsus Medical Center Nampa	SAMG Palliative Care Clinic- Nampa - Palliative Care	4400 E Flamingo Suite 130	Nampa	ID	Terminated

History

Section	Field	Action	Value Before	Value After	Timestamp
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	Update	Fry, Kenneth VP Finance 2083673445	Checketts, Lannie RHM CFO Idaho Oregon Region 2083677347	9/11/2017 3:29 PM
Contacts	Authorizing Official	Insert		Fry, Kenneth VP Finance 2083673445	8/9/2017 11:15 AM
Contacts	Signed By	Insert		KEELER, KARL CEO 2084635398	8/1/2017 2:17 PM
Addresses	Main Address	Insert		4402 E FLAMINGO AVE NAMPA, ID 83687-9203	4/21/2016 2:13 PM
Contacts	Primary Contact	Insert		Mallard, Barry Director of Pharmacy Services 2084635365	4/21/2016 2:13 PM
Dates	Last Date That 340B Drugs Purchased	Update		4/11/2016 12:00:00 AM	4/21/2016 2:13 PM
Details	State	Update	Active	Terminated	4/21/2016 2:13 PM
Terminations	Termination Date	Update		7/1/2016 12:00:00 AM	4/21/2016 2:13 PM
Terminations	Termination Effective Date	Update		4/11/2016 12:00:00 AM	4/21/2016 2:13 PM
Terminations	Termination Reason	Update		Site closure	4/21/2016 2:13 PM
Details	Last Recertification Date	Update		9/8/2015 12:00:00 AM	9/8/2015 4:30 PM
Details	Entity Subname	Update	NHP Birkeland Bldg	Saint Alphonsus Medical Center-Nampa Garrity Campus	7/7/2015 3:39 PM
Dates	Participating Approval Date	Update		5/14/2015 12:00:00 AM	5/14/2015 3:42 PM
Details	State	Update	Pending	Active	5/14/2015 3:42 PM
Dates	Start Date	Update		7/1/2015 12:00:00 AM	5/14/2015 3:42 PM
Details	340B ID	Update	OUTPATIENT_ONLINE_REG_51730	DSH130013D	5/7/2015 8:12 AM
Details	Entity Subname	Update	SAINT ALPHONSUS MEDICAL CENTER-NAMP / Saint Alphonsus Medical Center-Nampa NHP Birkeland Bldg	NHP Birkeland Bldg	5/7/2015 8:12 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_51730	4/15/2015 5:19 PM
Details	Last Recertification Date	Insert			4/15/2015 5:19 PM
Details	Grant Number	Insert			4/15/2015 5:19 PM
Details	340B ID	Insert			4/15/2015 5:19 PM
Details	Is Authorizing Official EHB Data	Insert			4/15/2015 5:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert			4/15/2015 5:19 PM
Details	Medicare Provider Number	Insert		130013	4/15/2015 5:19 PM
Details	Entity Name	Insert		SAINT ALPHONSUS MEDICAL CENTER-NAMPA	4/15/2015 5:19 PM
Details	Program Code	Insert		DSH	4/15/2015 5:19 PM
Details	Entity Subname	Insert		SAINT ALPHONSUS MEDICAL CENTER-NAMP / Saint Alphonsus Medical Center-Nampa NHP Birkeland Bldg	4/15/2015 5:19 PM
Dates	Participating Approval Date	Insert			4/15/2015 5:19 PM
Details	State	Insert		Pending	4/15/2015 5:19 PM
Dates	Registration Date	Insert		4/15/2015 12:00:00 AM	4/15/2015 5:19 PM
Dates	Signed By Date	Insert		4/15/2015 12:00:00 AM	4/15/2015 5:19 PM
Dates	Start Date	Insert			4/15/2015 5:19 PM
Terminations	Termination Comments	Insert			4/15/2015 5:19 PM
Terminations	Termination Date	Insert			4/15/2015 5:19 PM
Terminations	Termination Effective Date	Insert			4/15/2015 5:19 PM
Terminations	Termination Reason	Insert			4/15/2015 5:19 PM