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DSH130049Y 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
DSH130049Y
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
12/1/2017
Termination Date
Termination Reason
10/1/2018
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
920 W IRONWOOD DR STE 201
COEUR D ALENE, ID 83814-2463
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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