340B Drug Pricing Program Database
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CAH131321-04 ST. MARY'S HOSPITAL (Terminated)
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Main Details
Name
ST. MARY'S HOSPITAL
Subdivision Name
ST. MARY'S HOSPITAL CLINIC
Type
Critical Access Hospital
Rural
Yes
340B ID
CAH131321-04
Medicare Provider Number
131321
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
9/29/2010
Participating Start Date
9/30/2010
Participating Approval Date
9/30/2010
Last Recertification Date
11/21/2017
Termination Date
Termination Reason
4/1/2018
Business decision by the Covered Entity
Contacts
Authorizing Official
Clearwater Valley Hospital and St. Mary's Hospital
Jyl Ruland, CFO
(208) 476-8062
Primary Contact
Essentia Health
Bryan Lundberg, 340b Program Manager
(218) 828-7143
Addresses
Street Address
701 LEWISTON STREET
COTTONWOOD, ID 83522
Billing Address
ST. MARY'S HOSPITAL CLINIC
P.O BOX 137
COTTONWOOD, ID 83522
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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3/10/2011- UPDATED ADD (WAS 701 LEWISTON STREET)
03/10/2011
May 2025
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