Covered Entity Details

DSH130049AX KOOTENAI HEALTH INC (ToBeTerminated) - information as of 5/20/2025 12:51:41 AM

Main Details

Name

KOOTENAI HEALTH INC

Subdivision Name

Kootenai Clinic Nephrology - Nephrology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH130049AX

Medicare Provider Number

130049

Outpatient Facility Provider Number

Additional Details

Current Program Status

ToBeTerminated

Registration Date

6/16/2021

Participating Start Date

7/1/2021

Participating Approval Date

6/25/2021

Last Recertification Date

8/20/2024

Termination Date
Termination Reason

7/1/2025
Change of covered entity type

Contacts

Authorizing Official

Kootenai Health
Michele Bouit, CFO
(208) 625-4004

Primary Contact

Kootenai Health
Jim McDonald, Pharmacy - 340B Program Manager
(208) 625-5653

Addresses

Street Address

700 W Ironwood Dr
Suite 375
Coeur d'Alene, ID 83814

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating from effective date: (10/01/2018) until terminated effective date: (4/1/2019), reinstatement effective date: (07/01/2021)	06/25/2021

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
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		7/1/2025 12:00:00 AM	4/28/2025 2:42 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	4/28/2025 2:42 PM
Terminations	Termination Date	Update	Hospital Type Change Request		7/1/2025 12:00:00 AM	4/28/2025 2:42 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		7/1/2025 12:00:00 AM	4/28/2025 2:42 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	4/28/2025 2:42 PM
Details	Last Recertification Date	Update	Recertification	8/17/2023 3:51:36 PM	8/20/2024 5:03:17 PM	8/20/2024 5:03 PM
Details	Entity Name	Update	Change Request	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEALTH INC	2/21/2024 11:16 AM
Details	Last Recertification Date	Update	Recertification	9/13/2022 3:14:51 PM	8/17/2023 3:51:36 PM	8/17/2023 3:51 PM
Contacts	Authorizing Official	Update	Change Request	Webb, Kim CFO Kootenai Health 2086254001	Bouit, Michele CFO Kootenai Health 2086254004	1/17/2023 6:59 AM
Details	Last Recertification Date	Update	Recertification	8/20/2021 4:39:57 PM	9/13/2022 3:14:51 PM	9/13/2022 3:14 PM
Details	Last Recertification Date	Update	Recertification		8/20/2021 4:39:57 PM	8/20/2021 4:39 PM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Primary Contact	Update	Reinstatement	Chapman, Timothy J. Pharmacy Business Manager Kootenai Health 2086255651	McDonald, Jim Pharmacy - 340B Program Manager Kootenai Health 2086255653	6/25/2021 11:22 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	3/31/2019 12:00:00 AM		6/25/2021 11:22 AM
Dates	Participating Approval Date	Update	Reinstatement	8/8/2018 11:14:50 AM	6/25/2021 11:22:40 AM	6/25/2021 11:22 AM
Details	State	Update	Reinstatement	Terminated	Approved	6/25/2021 11:22 AM
Dates	Registration Date	Update	Reinstatement	7/17/2018 2:40:43 PM	6/16/2021 2:23:56 PM	6/25/2021 11:22 AM
Dates	Signed By Date	Update	Reinstatement	7/17/2018 4:10:49 PM	6/23/2021 3:54:52 PM	6/25/2021 11:22 AM
Dates	Start Date	Update	Reinstatement	10/1/2018 12:00:00 AM	7/1/2021 12:00:00 AM	6/25/2021 11:22 AM
Terminations	Termination Comments	Update	Reinstatement	We believe our DSH percentage will be going below 11.75 We are being proactive and will be going from DSH to RRC to avoid a lapse in coverage.		6/25/2021 11:22 AM
Terminations	Termination Date	Update	Reinstatement	4/1/2019 12:00:00 AM		6/25/2021 11:22 AM
Terminations	Termination Effective Date	Update	Reinstatement	4/1/2019 12:00:00 AM		6/25/2021 11:22 AM
Terminations	Termination Reason	Update	Reinstatement	DSH percentage below statutory minimum		6/25/2021 11:22 AM
Details	Comments Public	Insert	Reinstatement		Participating from effective date: (10/01/2018) until terminated effective date: (4/1/2019), reinstatement effective date: (07/01/2021)	6/25/2021 7:09 AM
Details	State	Update		To Be Terminated	Terminated	4/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		3/31/2019 12:00:00 AM	1/9/2019 2:34 PM
Details	State	Update	Termination Request	Active	To Be Terminated	1/9/2019 2:34 PM
Terminations	Termination Comments	Update	Termination Request		We believe our DSH percentage will be going below 11.75 We are being proactive and will be going from DSH to RRC to avoid a lapse in coverage.	1/9/2019 2:34 PM
Terminations	Termination Date	Update	Termination Request		4/1/2019 12:00:00 AM	1/9/2019 2:34 PM
Terminations	Termination Effective Date	Update	Termination Request		4/1/2019 12:00:00 AM	1/9/2019 2:34 PM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	1/9/2019 2:34 PM
Details	State	Update		Approved	Active	10/1/2018 12:05 AM
Contacts	Signed By	Insert	New Registration		Webb, Kim CFO Kootenai Health 2086254001	8/8/2018 11:14 AM
Details	340B ID	Update	New Registration		DSH130049AX	8/8/2018 11:14 AM
Details	Entity Subname	Update	New Registration	Kootenai Clinic Nephrology	Kootenai Clinic Nephrology - Nephrology	8/8/2018 11:14 AM
Dates	Participating Approval Date	Update	New Registration		8/8/2018 11:14:50 AM	8/8/2018 11:14 AM
Details	State	Update	New Registration	Pending	Approved	8/8/2018 11:14 AM
Dates	Signed By Date	Update	New Registration		7/17/2018 4:10:49 PM	8/8/2018 11:14 AM
Dates	Start Date	Update	New Registration		10/1/2018 12:00:00 AM	8/8/2018 11:14 AM
Addresses	Main Address	Insert	New Registration		700 W Ironwood Dr Suite 375 Coeur d'Alene, ID 83814	7/17/2018 2:40 PM
Contacts	Primary Contact	Insert	New Registration		Chapman, Timothy J. Pharmacy Business Manager Kootenai Health 2086255651	7/17/2018 2:40 PM
Contacts	Authorizing Official	Insert	New Registration		Webb, Kim CFO Kootenai Health 2086254001	7/17/2018 2:40 PM
Details	Last Recertification Date	Insert	New Registration			7/17/2018 2:40 PM
Details	Grant Number	Insert	New Registration			7/17/2018 2:40 PM
Details	340B ID	Insert	New Registration			7/17/2018 2:40 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/17/2018 2:40 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/17/2018 2:40 PM
Details	Medicare Provider Number	Insert	New Registration		130049	7/17/2018 2:40 PM
Details	Entity Name	Insert	New Registration		KOOTENAI HOSPITAL DISTRICT	7/17/2018 2:40 PM
Details	Program Code	Insert	New Registration		DSH	7/17/2018 2:40 PM
Details	Entity Subname	Insert	New Registration		Kootenai Clinic Nephrology	7/17/2018 2:40 PM
Dates	Participating Approval Date	Insert	New Registration			7/17/2018 2:40 PM
Details	State	Insert	New Registration		Pending	7/17/2018 2:40 PM
Dates	Registration Date	Insert	New Registration		7/17/2018 2:40:43 PM	7/17/2018 2:40 PM
Dates	Signed By Date	Insert	New Registration			7/17/2018 2:40 PM
Dates	Start Date	Insert	New Registration			7/17/2018 2:40 PM
Terminations	Termination Comments	Insert	New Registration			7/17/2018 2:40 PM
Terminations	Termination Date	Insert	New Registration			7/17/2018 2:40 PM
Terminations	Termination Effective Date	Insert	New Registration			7/17/2018 2:40 PM
Terminations	Termination Reason	Insert	New Registration			7/17/2018 2:40 PM