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RRC130049-39 KOOTENAI HOSPITAL DISTRICT (Terminated)
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Main Details
Name
KOOTENAI HOSPITAL DISTRICT
Subdivision Name
KOOTENAI CLINIC HAND SURGERY - HAND SURGERY
Type
Rural Referral Center
Rural
No
340B ID
RRC130049-39
Medicare Provider Number
130049
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/10/2019
Participating Start Date
4/1/2019
Participating Approval Date
2/1/2019
Last Recertification Date
8/25/2020
Termination Date
Termination Reason
7/1/2021
Change of covered entity type
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
2121 W IRONWOOD DR.
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 Start Date 4/1/2019, Termination Date 7/1/2021, Reinstatement 7/1/2024
04/30/2024
May 2025
May 2025
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