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DSH130049L KOOTENAI MEDICAL CENTER (Terminated)
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Main Details
Name
KOOTENAI MEDICAL CENTER
Subdivision Name
KOOTENAI CLINIC FAMILY MEDICINE
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH130049L
Medicare Provider Number
130049
Outpatient Facility Provider Number
130049
Additional Details
Current Program Status
Terminated
Registration Date
7/14/2014
Participating Start Date
10/1/2014
Participating Approval Date
9/10/2014
Last Recertification Date
8/27/2015
Termination Date
Termination Reason
10/1/2015
Site closure
Contacts
Authorizing Official
Kootenai Health
Kim Webb, CFO
(208) 625-4001
Primary Contact
Kootenai Health
Timothy J. Chapman, Pharmacy Business Manager
(208) 625-5651
Addresses
Street Address
16760 N HWY 41
RATHDRUM, ID 83858-8715
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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