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DSH130025 MADISON MEMORIAL HOSPITAL (Active)
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Main Details
Name
MADISON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH130025
Medicare Provider Number
130025
Additional Details
Current Program Status
Active
Registration Date
6/9/2009
Participating Start Date
7/1/2009
Participating Approval Date
6/14/2009
Last Recertification Date
8/21/2024
Contacts
Authorizing Official
Madison Memorial Hospital
Rachel Gonzales, CEO
(208) 356-3691
Primary Contact
Madison Memorial Hospital
David A Kennedy, Pharmacy Director
(208) 359-6484
Addresses
Street Address
450 EAST MAIN
REXBURG, ID 83440
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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1/18/2012 Change AO from Harrison to Gonzales 9/23/10 REMOVE MEDI # (WAS 002855900)
01/18/2012
9/23/10 REMOVE MEDI # (WAS 002855900)
10/14/2010
May 2025
May 2025
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