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DSH130007DB ST. ALPHONSUS REGIONAL MED CENTER (Terminated)
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Main Details
Name
ST. ALPHONSUS REGIONAL MED CENTER
Subdivision Name
SAMG Cherry Lane Family Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH130007DB
Medicare Provider Number
130007
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/13/2015
Participating Start Date
4/1/2015
Participating Approval Date
3/11/2015
Last Recertification Date
Termination Date
Termination Reason
10/1/2015
Site closure
Contacts
Authorizing Official
Saint Alphonsus Health System
Lannie Checketts, RHM CFO Idaho Oregon Region
(208) 367-7347
Primary Contact
Mark Phillips, Director of Pharmacy
(208) 367-4943
Addresses
Street Address
3250 W Cherry Lane
Meridian, ID 83642
Billing Address
SAMG Cherry Lane Family Clinic
1055 N. Curtis Rd.
Boise, ID 83706
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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