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DSH130049W KOOTENAI HEALTH INC (ToBeTerminated)
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Main Details
Name
KOOTENAI HEALTH INC
Subdivision Name
KOOTENAI CLINIC INTERNAL MEDICINE
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH130049W
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
1919 LINCOLN WAY #110
COEUR D'ALENE, ID 83814
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)
06/24/2021
May 2025
May 2025
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