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DSH130049G KOOTENAI HEALTH INC (ToBeTerminated)
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Main Details
Name
KOOTENAI HEALTH INC
Subdivision Name
KOOTENAI CLINIC EAR NOSE THROAT & ALLERGY
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH130049G
Medicare Provider Number
130049
Outpatient Facility Provider Number
130049
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 STE 278
COEUR D ALENE, ID 83814-4400
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date: (10/1/2014) until terminated effective date: (4/1/2019), reinstatement effective date: (07/01/2021)
06/25/2021
May 2025
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