340B Drug Pricing Program Database
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DSH130049X KOOTENAI HOSPITAL DISTRICT (Terminated)
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Main Details
Name
KOOTENAI HOSPITAL DISTRICT
Subdivision Name
KOOTENAI CLINIC INTERNAL MEDICINE
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH130049X
Medicare Provider Number
130049
Outpatient Facility Provider Number
130049
Additional Details
Current Program Status
Terminated
Registration Date
6/16/2021
Participating Start Date
7/1/2021
Participating Approval Date
6/25/2021
Last Recertification Date
8/20/2021
Termination Date
Termination Reason
1/1/2022
Business decision by the Covered Entity
Contacts
Authorizing Official
Kootenai Health
Kim Webb, CFO
(208) 625-4001
Primary Contact
Kootenai Health
Jim McDonald, Pharmacy - 340B Program Manager
(208) 625-5653
Addresses
Street Address
1701 LINCOLN WAY
COEUR D ALENE, ID 83814-2537
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date: (10/01/2014) until terminated effective date: (4/1/2019), reinstatement effective date: (07/01/2021)
06/25/2021
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