Covered Entity Details

DSH130049 KOOTENAI HEALTH INC (ToBeTerminated) - information as of 5/11/2025 11:29:32 PM

Main Details

Name

KOOTENAI HEALTH INC

Subdivision Name

KOOTENAI HEALTH

Type

Disproportionate Share Hospital

Rural

340B ID

DSH130049

Medicare Provider Number

130049

Additional Details

Current Program Status

ToBeTerminated

Registration Date

6/16/2021

Participating Start Date

7/1/2021

Participating Approval Date

6/22/2021

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

2003 Kootenai Health Way
COEUR DALENE, ID 83814

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating from effective date: (10/1/2014) until terminated effective date: (4/1/2019), reinstatement effective date: (06/22/21)	06/22/2021

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Shipping Address 1

Kootenai Health
2003 Kootenai Health Way
Coeur d'Alene, ID 83814

Shipping Address 2

Kootenai Health Pharmacy
700 W Ironwood Drive
159
Coeur d'Alene, ID 83814

Shipping Address 3

Kootenai Health Pharmacy Hayden
8882 N Government Way
Suite L
Hayden, ID 83835

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	10/17/2017	01/01/2018	04/01/2019	04/01/2019
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/17/2017	01/01/2018	04/01/2019	04/01/2019
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/17/2017	01/01/2018	04/01/2019	04/01/2019
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	06/29/2021	07/01/2021	01/26/2024	01/26/2024
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	10/17/2017	01/01/2018	04/01/2019	04/01/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/17/2017	01/01/2018	04/01/2019	04/01/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/17/2017	01/01/2018	04/01/2019	04/01/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	06/29/2021	07/01/2021	01/26/2024	01/26/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	06/29/2021	07/01/2021	01/26/2024	01/26/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	06/29/2021	07/01/2021	01/26/2024	01/26/2024
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	ALBERTSON'S LLC	SAFEWAY PHARMACY #265	6520 N NEVADA ST	SPOKANE	WA	99208	07/13/2016	10/01/2016	10/01/2016	07/28/2017
Contract Detail	ALBERTSON'S LLC	SAFEWAY PHARMACY #258	13606 E 32ND AVE	SPOKANE	WA	99216	07/13/2016	10/01/2016	10/01/2016	07/28/2017
Contract Detail	ALBERTSON'S LLC	SAFEWAY PHARMACY #2248	1304 N. LIBERTY LAKE RD.	LIBERTY LAKE	WA	99019	01/05/2017	04/01/2017	04/01/2019	04/01/2019
Contract Detail	ALBERTSONS LLC	SAFEWAY PHARMACY #254	161 W PRAIRIE AVE	HAYDEN	ID	83835	07/13/2016	10/01/2016	04/01/2019	04/01/2019
Contract Detail	AMBER PHARMACY	AMBER ENTERPRISES, INC.	10004 S 152ND STREET SUITE A	OMAHA	NE	68138-3931	10/18/2018	01/01/2019	04/01/2019	04/01/2019
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	04/06/2018	07/01/2018	04/01/2019	04/01/2019
Contract Detail	AVELLA OF SACRAMENTO, INC.	2288 AUBURN BLVD #102		SACRAMENTO	CA	95821	04/06/2018	07/01/2018	04/01/2019	04/01/2019
Contract Detail	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	01/05/2018	04/01/2018	04/01/2019	04/01/2019
Contract Detail	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	01/05/2018	04/01/2018	04/01/2019	04/01/2019
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	11660 WEST EXECUTIVE DRIVE	BOISE	ID	83713-8996	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	7358 S W DURHAM ROAD	PORTLAND	OR	97224	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	5511 E 3RD AVE	SPOKANE VALLEY	WA	99212-0726	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	5511 E 3RD AVE	SPOKANE VALLEY	WA	99212-0726	06/29/2021	07/01/2021	01/17/2025	04/14/2025
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	11660 WEST EXECUTIVE DRIVE	BOISE	ID	83713-8996	06/29/2021	07/01/2021	01/17/2025	04/14/2025
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	7358 S W DURHAM ROAD	PORTLAND	OR	97224	06/29/2021	07/01/2021	01/17/2025	04/14/2025
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	01/17/2017	04/01/2017	08/09/2017	08/09/2017
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	06/28/2017	07/01/2017	04/01/2019	04/01/2019
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	01/17/2018	04/01/2018	04/01/2019	04/01/2019
Contract Detail	DOC'S PHARMACY INC.	MEDICINE MAN SANDPOINT	624 LARCH ST	SANDPOINT	ID	83864-8383	07/10/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	DOC'S PHARMACY INC.	MEDICINE MAN SANDPOINT	624 LARCH ST	SANDPOINT	ID	83864-8383	06/29/2021	07/01/2021	08/11/2022	09/13/2022
Contract Detail	DOC'S PHARMACY LLC	DBA RATHDRUM DRUG	16438 N HIGHWAY 41	RATHDRUM	ID	83858	06/29/2021	07/01/2021	12/26/2023	01/03/2024
Contract Detail	FRED MEYER	560 WEST KATHLEEN AVE		COEUR D ALENE	ID	83815-8392	10/17/2016	01/01/2017	04/01/2019	04/01/2019
Contract Detail	FRED MEYER	560 WEST KATHLEEN AVE		COEUR D ALENE	ID	83815-8392	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	FRED MEYER STORES, INC	FRED MEYER PHARMACY 351	15609 EAST SPRAGUE AVE	SPOKANE VALLEY	WA	99037	10/17/2016	01/01/2017	04/01/2019	04/01/2019
Contract Detail	FRED MEYER STORES, INC	FRED MEYER PHARMACY 351	15609 EAST SPRAGUE AVE	SPOKANE VALLEY	WA	99037	06/29/2021	07/01/2021	11/20/2023	01/03/2024
Contract Detail	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	10/17/2016	01/01/2017	04/01/2019	04/01/2019
Contract Detail	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	INTERLAKE PHARMACY	700 W IRONWOOD DR STE 159		COEUR D ALENE	ID	83814-4401	04/10/2015	07/01/2015	04/01/2019	04/01/2019
Contract Detail	JACKS PHARMACY INC	103 E COLLEGE AVE		ST MARIES	ID	83861	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	KMART PHARMACY		4110 E SPRAGUE AVENUE	SPOKANE	WA	99202	04/13/2016	07/01/2016	09/12/2017	09/28/2017
Contract Detail	KMART PHARMACY		W 201 NEIDER ROAD	COEUR D'ALENE	ID	83815	04/13/2016	07/01/2016	09/12/2017	09/28/2017
Contract Detail	KOHAL PHARMACY INC	KOHAL PHARMACY INC	800 BANK ST	WALLACE	ID	83873	04/11/2023	05/10/2023	01/26/2024	01/26/2024
Contract Detail	KOHAL PHARMACY INCORPORATED	KOHAL PHARMACY, INC.	740 MCKINLEY AVE	KELLOGG	ID	83837-2693	04/11/2023	05/10/2023	01/26/2024	01/26/2024
Contract Detail	KOHAL PHARMACY, INC.	KOHAL PHARMACY INCORPORATED	504 N. DIVISION PO BOX 400	PINEHURST	ID	83850	04/11/2023	05/10/2023	01/26/2024	01/26/2024
Contract Detail	MEDICINE MAN ATHOL PHARMACY	30585 N ROBERTS RD		ATHOL	ID	83801	07/19/2018	10/01/2018	04/01/2019	04/01/2019
Contract Detail	MEDICINE MAN ATHOL PHARMACY	30585 N ROBERTS RD		ATHOL	ID	83801	06/29/2021	07/01/2021	12/31/2022	12/31/2022
Contract Detail	MEDICINE MAN ATHOL PHARMACY	30585 N ROBERTS RD		ATHOL	ID	83801	10/12/2022	01/01/2023	08/20/2024	08/20/2024
Contract Detail	MEDICINE MAN BONNERS FERRY PHARMACY	6452 MAIN ST		BONNERS FERRY	ID	83805-8520	04/07/2015	07/01/2015	07/01/2015	07/28/2017
Contract Detail	MEDICINE MAN HAYDEN PHARMACY	240 W HAYDEN AVE		HAYDEN	ID	83835-8194	10/12/2022	01/01/2023	08/20/2024	08/20/2024
Contract Detail	MEDICINE MAN NORTH PHARMACY	INC DBA MEDICINE MAN PRAIRIE	8093 N CORNERSTONE DR	HAYDEN	ID	83835-8753	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	MEDICINE MAN NORTH PHARMACY	305 W KATHLEEN AVE		COEUR D ALENE	ID	83815	01/05/2016	04/01/2016	04/01/2019	04/01/2019
Contract Detail	MEDICINE MAN NORTH PHARMACY	INC DBA MEDICINE MAN PRAIRIE	8093 N CORNERSTONE DR	HAYDEN	ID	83835-8753	06/29/2021	07/01/2021	12/31/2022	12/31/2022
Contract Detail	MEDICINE MAN NORTH PHARMACY	305 W KATHLEEN AVE		COEUR D ALENE	ID	83815	06/29/2021	07/01/2021	12/31/2022	12/31/2022
Contract Detail	MEDICINE MAN NORTH PHARMACY	MEDICINE MAN NORTH PHARMACY	305 W KATHLEEN AVE	COEUR D ALENE	ID	83815	10/12/2022	01/01/2023	08/20/2024	08/20/2024
Contract Detail	MEDICINE MAN NORTH PHCY INC	DBA MEDICINE MAN HAYDEN PHCY	240 W HAYDEN AVE PO BOX 1706	HAYDEN	ID	83835	01/05/2016	04/01/2016	04/01/2019	04/01/2019
Contract Detail	MEDICINE MAN NORTH PHCY INC	DBA MEDICINE MAN HAYDEN PHCY	240 W HAYDEN AVE PO BOX 1706	HAYDEN	ID	83835	06/29/2021	07/01/2021	12/31/2022	12/31/2022
Contract Detail	MEDICINE MAN PHARMACY INC	1114 W IRONWOOD DR		COEUR D ALENE	ID	83814-2605	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	MEDICINE MAN PRAIRIE PHARMACY	8093 N CORNERSTONE DR	MEDICINE MAN PRAIRIE PHARMACY	HAYDEN	ID	83835	10/12/2022	01/01/2023	08/20/2024	08/20/2024
Contract Detail	MEDICINE MAN RATHDRUM	15837 N WESTWOOD DR		RATHDRUM	ID	83858-6432	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	MEDICINE MAN RATHDRUM	15837 N WESTWOOD DR		RATHDRUM	ID	83858-6432	06/29/2021	07/01/2021	07/22/2024	07/22/2024
Contract Detail	MEDICINE MAN SOUTHWEST	805 E POLSTON AVE		POST FALLS	ID	83854	01/14/2016	04/01/2016	04/01/2019	04/01/2019
Contract Detail	MEDICINE MAN SOUTHWEST	805 E POLSTON AVE		POST FALLS	ID	83854	06/29/2021	07/01/2021	07/22/2024	07/22/2024
Contract Detail	MEDICINE MAN WEST PHARMACY	802 E MEDICAL CT		POST FALLS	ID	83854-7298	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	MEDICINE MAN WEST PHARMACY	802 E MEDICAL CT		POST FALLS	ID	83854-7298	06/29/2021	07/01/2021	07/22/2024	07/22/2024
Contract Detail	OPTION CARE ENTERPRISES, INC.	D/B/A OPTION CARE	11403 BLUEGRASS PARKWAY SUITE 400	LOUISVILLE	KY	40299-2398	07/12/2016	10/01/2016	04/01/2019	04/01/2019
Contract Detail	OPTION CARE ENTERPRISES, INC.	D/B/A OPTION CARE	3310 N. PINES RD.	SPOKANE VALLEY	WA	99206-2804	07/12/2016	10/01/2016	04/01/2019	04/01/2019
Contract Detail	OPTION CARE ENTERPRISES, INC.	D/B/A OPTION CARE	11403 BLUEGRASS PARKWAY SUITE 400	LOUISVILLE	KY	40299-2398	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	OPTION CARE ENTERPRISES, INC.	D/B/A OPTION CARE	3310 N. PINES RD.	SPOKANE VALLEY	WA	99206-2804	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	01/05/2018	04/01/2018	04/01/2019	04/01/2019
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/05/2018	04/01/2018	04/01/2019	04/01/2019
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	01/05/2018	04/01/2018	04/01/2019	04/01/2019
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	01/05/2018	04/01/2018	04/01/2019	04/01/2019
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	06/30/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/18/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	06/29/2021	07/01/2021	10/01/2022	10/12/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/06/2017	10/01/2017	04/01/2019	04/01/2019
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2926	1001 MADISON ST.	SEATTLE	WA	98104	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #2954	6519 MAIN STREET	BONNERS FERRY	ID	83805	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1470	121 W NEIDER AVENUE	COEUR D ALENE	ID	83815	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #3295	1001 N FOURTH STREET	COEUR D ALENE	ID	83814-3113	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1473	14020 E SPRAGUE AVE	SPOKANE VALLEY	WA	99216	07/13/2016	10/01/2016	10/01/2016	07/28/2017
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0350	702 N. 5TH AVENUE	SANDPOINT	ID	83864	07/13/2016	10/01/2016	04/01/2019	04/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1159	121 W. WALNUT ST	NEWPORT	WA	99156	07/13/2016	10/01/2016	04/01/2019	04/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #3247	101 GRAND COULEE HWY PO BOX 50	GRAND COULEE	WA	99133	07/13/2016	10/01/2016	10/01/2016	07/28/2017
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0383	1320 S BLAINE STREET	MOSCOW	ID	83843-3971	07/13/2016	10/01/2016	10/01/2016	07/28/2017
Contract Detail	SANDPOINT SUPER DRUG	604 N FIFTH AVE.		SANDPOINT	ID	83864	01/05/2017	04/01/2017	04/01/2019	04/01/2019
Contract Detail	SANDPOINT SUPER DRUG	604 N FIFTH AVE.		SANDPOINT	ID	83864	06/29/2021	07/01/2021	10/23/2022	10/23/2022
Contract Detail	SANDPOINT SUPER DRUG	604 N FIFTH AVE.		SANDPOINT	ID	83864	04/14/2023	05/10/2023	01/26/2024	01/26/2024
Contract Detail	SHOPKO PHARMACY #2069	217 WEST IRONWOOD DRIVE		COEUR D'ALENE	ID	83814	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/11/2023	05/10/2023	07/01/2025	04/28/2025
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/11/2023	05/10/2023	07/01/2025	04/28/2025
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5420	208 WEST IRONWOOD DRIVE	COEUR D'ALENE	ID	83814	10/14/2015	01/01/2016	04/01/2019	04/01/2019
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6200	43 WEST PRAIRIE SHOPPING CTR	HAYDEN	ID	83835	10/14/2015	01/01/2016	04/01/2019	04/01/2019
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5420	208 WEST IRONWOOD DRIVE	COEUR D'ALENE	ID	83814	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6200	43 WEST PRAIRIE SHOPPING CTR	HAYDEN	ID	83835	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/12/2018	01/01/2019	04/01/2019	04/01/2019
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WAL-MART PHARMACY 10-2485	476999 HWY 95 NORTH		PONDERAY	ID	83852	10/05/2016	01/01/2017	04/01/2019	04/01/2019
Contract Detail	WAL-MART PHARMACY 10-2485	476999 HWY 95 NORTH		PONDERAY	ID	83852	06/29/2021	07/01/2021	12/11/2023	01/03/2024
Contract Detail	WAL-MART PHARMACY 10-3472	3050 EAST MULLAN AVENUE		POST FALLS	ID	83854	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	WAL-MART PHARMACY 10-3472	3050 EAST MULLAN AVENUE		POST FALLS	ID	83854	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WAL-MART PHARMACY 10-3511	550 W. HONEYSUCKLE AVE.		HAYDEN	ID	83835	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	WAL-MART PHARMACY 10-3511	550 W. HONEYSUCKLE AVE.		HAYDEN	ID	83835	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WAL-MART PHARMACY 10-4395	6405 W POINTE PARKWAY		POST FALLS	ID	83854	10/05/2016	01/01/2017	04/01/2019	04/01/2019
Contract Detail	WAL-MART PHARMACY 10-4395	6405 W POINTE PARKWAY		POST FALLS	ID	83854	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/12/2018	01/01/2019	04/01/2019	04/01/2019
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06863	335 W APPLEWAY AVE	COEUR D ALENE	ID	83814	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07949	706 E SELTICE WAY	POST FALLS	ID	83854	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10314	260 W HONEYSUCKLE AVE	HAYDEN	ID	83835-9270	09/16/2014	10/01/2014	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #07846	2702 N. ARGONNE RD.	MILLWOOD	WA	99212	10/03/2014	10/06/2014	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05914	15510 E SPRAGUE	SPOKANE VALLEY	WA	99037	10/03/2014	10/06/2014	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01993	12312 E SPRAGUE AVE	SPOKANE VALLEY	WA	99216-0720	04/12/2017	07/01/2017	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02205	12315 N DIVISION ST	SPOKANE	WA	99218	04/12/2017	07/01/2017	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05913	7905 N DIVISION ST	SPOKANE	WA	99208	04/12/2017	07/01/2017	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10788	1502 N. LIBERTY LAKE RD.	LIBERTY LAKE	WA	99019-8631	04/12/2017	07/01/2017	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #21243	327 W 3RD AVE STE A	SPOKANE	WA	99201	04/12/2017	07/01/2017	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07034	12 E EMPIRE AVE	SPOKANE	WA	99207-1706	01/05/2018	04/01/2018	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10946	2830 S. GRAND BLVD.	SPOKANE	WA	99203	01/05/2018	04/01/2018	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05817	1708 W NORTHWEST BLVD	SPOKANE	WA	99205	01/05/2018	04/01/2018	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15643	910 W. FIFTH AVENUE SUITE 270	SPOKANE	WA	99204	01/05/2018	04/01/2018	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05818	2105 E WELLESLEY AVE	SPOKANE	WA	99207	07/19/2018	10/01/2018	04/01/2019	04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02205	12315 N DIVISION ST	SPOKANE	WA	99218	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05818	2105 E WELLESLEY AVE	SPOKANE	WA	99207	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10946	2830 S. GRAND BLVD.	SPOKANE	WA	99203	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10314	260 W HONEYSUCKLE AVE	HAYDEN	ID	83835-9270	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05914	15510 E SPRAGUE	SPOKANE VALLEY	WA	99037	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07949	706 E SELTICE WAY	POST FALLS	ID	83854	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10788	1502 N. LIBERTY LAKE RD.	LIBERTY LAKE	WA	99019-8631	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05913	7905 N DIVISION ST	SPOKANE	WA	99208	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07034	12 E EMPIRE AVE	SPOKANE	WA	99207-1706	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05817	1708 W NORTHWEST BLVD	SPOKANE	WA	99205	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01993	12312 E SPRAGUE AVE	SPOKANE VALLEY	WA	99216-0720	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06863	335 W APPLEWAY AVE	COEUR D ALENE	ID	83814	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #21243	327 W 3RD AVE STE A	SPOKANE	WA	99201	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #07846	2702 N. ARGONNE RD.	MILLWOOD	WA	99212	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15643	910 W. FIFTH AVENUE SUITE 270	SPOKANE	WA	99204	06/29/2021	07/01/2021	09/29/2022	10/12/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/17/2017	04/01/2017	04/01/2019	04/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	01/17/2017	04/01/2017	04/01/2019	04/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/17/2017	04/01/2017	04/01/2019	04/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/17/2017	04/01/2017	04/01/2019	04/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	06/29/2021	07/01/2021	10/01/2021	10/05/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	06/29/2021	07/01/2021	07/01/2025	04/28/2025
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/14/2023	07/01/2023	07/01/2025	04/28/2025
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/16/2023	01/01/2024	07/01/2025	04/28/2025
Contract Detail	WELLPARTNER, INC	20800 SW 115TH AVE	SUITE 100	TUALATIN	OR	97062	10/01/2015	01/01/2016	07/04/2018	07/20/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH130049AA	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Neurology	700 Ironwood Dr. #158	Coeur d'Alene	ID	ToBeTerminated
DSH130049AB	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE	1300 E MULLAN AVE #1300	POST FALLS	ID	ToBeTerminated
DSH130049AC	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC PLASTIC AND RECONSTRUCTIVE SURGERY	980 W. Ironwood Drive, Suite 01	Coeur d'Alene	ID	ToBeTerminated
DSH130049AD	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI HEART CLINICS NORTHWEST	700 W IRONWOOD DR #320	COEUR D ALENE	ID	ToBeTerminated
DSH130049AE	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC PSYCHIATRY	2199 Ironwood Center Drive	Coeur d'Alene	ID	Terminated
DSH130049AF	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEART CLINICS NORTHWEST	423 N 3RD AVE #355	SANDPOINT	ID	Terminated
DSH130049AG	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEART CLINICS NORTHWEST	122 W 7TH AVE STE 310	SPOKANE	WA	Terminated
DSH130049AH	Child	DSH	KOOTENAI HOSPITAL DISTRICT	MCGRANE CENTER FOR REHABILITATION	2003 Kootenai Health Way	Coeur d'Alene	ID	Terminated
DSH130049AJ	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI OUTPATIENT IMAGING	1300 East Mullan Avenue STE 700	Post Falls	ID	Terminated
DSH130049AK	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI OUTPATIENT IMAGING	1919 Lincoln Way STE #111	Coeur d'Alene	ID	Terminated
DSH130049AL	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI OUTPATIENT IMAGING	700 West Ironwood, STE 175	Coeur d'Alene	ID	Terminated
DSH130049AM	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEART CLINICS NORTHWEST	212 E CENTRAL STE #335	SPOKANE	WA	Terminated
DSH130049AN	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI HEALTH - ADVANCED HEART DISEASE MANAGEMENT CLINIC/ELECTROPHYSIOLOGY	700 W IRONWOOD DRIVE, SUITE 350	Coeur d' Alene	ID	ToBeTerminated
DSH130049AP	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI HEART CLINICS NORTHWEST	1300 E MULLAN AVE 900	POST FALLS	ID	ToBeTerminated
DSH130049AQ	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEART CLINICS NORTHWEST	13102 E MISSION AVE	SPOKANE VALLEY	WA	Terminated
DSH130049AR	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC VASCULARY SURGERY	700 IRONWOOD DR SUITE 350	COEUR D ALENE	ID	ToBeTerminated
DSH130049AS	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC - SLEEP MEDICINE	700 Ironwood Drive	COEUR D'ALENE	ID	ToBeTerminated
DSH130049AT	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC - ORTHOPEDICS POST FALLS	1296 E Polston Ave Ste C	Post Falls	ID	ToBeTerminated
DSH130049AU	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Cancer Services	700 W Ironwood Dr., Suite #230	Coeur d' Alene	ID	ToBeTerminated
DSH130049AV	Child	DSH	KOOTENAI HOSPITAL DISTRICT	Kootenai Clinic Neurosurgery	700 W Ironwood Dr Ste 258	Coeur d' Alene	ID	Terminated
DSH130049AW	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic - Orthopedics	2177 W. Ironwood Center Drive	Couer d' Alene	ID	ToBeTerminated
DSH130049AX	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Nephrology - Nephrology	700 W Ironwood Dr	Coeur d'Alene	ID	ToBeTerminated
DSH130049AY	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Wound Care - Wound Care, Infectious Disease	2120 W. Ironwood Center Dr.	Coeur d'Alene	ID	ToBeTerminated
DSH130049AZ	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC LUNG & ASTHMA - LUNG & ASTHMA	706 W IRONWOOD DR	COEUR D'ALENE	ID	ToBeTerminated
DSH130049B	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC CANCER SERVICES	1440 E MULLAN AVE	POST FALLS	ID	ToBeTerminated
DSH130049BA	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE CDA IRONWOOD - FAMILY MEDICINE	914 W IRONWOOD DR	COEUR D'ALENE	ID	ToBeTerminated
DSH130049BB	Child	DSH	KOOTENAI HEALTH INC	ANTICOAGULATION CLINIC - ANTICOAG CLINIC	700 IRONWOOD DRIVE	COEUR D'ALENE	ID	ToBeTerminated
DSH130049C	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC CANCER SERVICES	700 W IRONWOOD DR #130	COEUR D ALENE	ID	ToBeTerminated
DSH130049D	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC CANCER SERVICES	520 N THIRD AVE	SANDPOINT	ID	ToBeTerminated
DSH130049E	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC DIABETES AND ENDOCRINOLOGY	1919 LINCOLN WAY #211	COEUR D'ALENE	ID	ToBeTerminated
DSH130049F	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC EAR NOSE THROAT & ALLERGY	420 N 2ND AVE STE #300	SANDPOINT	ID	Terminated
DSH130049G	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC EAR NOSE THROAT & ALLERGY	700 W IRONWOOD DR STE 278	COEUR D ALENE	ID	ToBeTerminated
DSH130049H	Child	DSH	KOOTENAI MEDICAL CENTER	KOOTENAI FAMILY & INTERNAL MEDICINE	925 E POLSTON AVENUE	POST FALLS	ID	Terminated
DSH130049J	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE	1701 LINCOLN WAY	COEUR D ALENE	ID	ToBeTerminated
DSH130049K	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE	566 W PRAIRIE AVENUE	COEUR D ALENE	ID	ToBeTerminated
DSH130049L	Child	DSH	KOOTENAI MEDICAL CENTER	KOOTENAI CLINIC FAMILY MEDICINE	16760 N HWY 41	RATHDRUM	ID	Terminated
DSH130049M	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC FAMILY MEDICINE CDA RESIDENCY	1919 LINCOLN WAY #315	COEUR D'ALENE	ID	ToBeTerminated
DSH130049N	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Gastroenterology	1919 Lincoln Way #415	Coeur d'Alene	ID	ToBeTerminated
DSH130049P	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Gastroenterology & Endoscopy	1919 Lincoln Way #416	Coeur d'Alene	ID	ToBeTerminated
DSH130049Q	Child	DSH	KOOTENAI HEALTH INC	Kootenai Clinic Hand Surgery	2121 W. Ironwood Center Dr.	Coeur d'Alene	ID	ToBeTerminated
DSH130049R	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC OBSTETRICS & GYNECOLOGY	1300 E MULLAN AVE STE 500	POST FALLS	ID	ToBeTerminated
DSH130049S	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC OBSTETRICS & GYNECOLOGY	980 W IRONWOOD DR STE 306	COEUR D ALENE	ID	ToBeTerminated
DSH130049T	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC INTERNAL MEDICINE	1300 E MULLAN AVE STE 1600	POST FALLS	ID	ToBeTerminated
DSH130049U	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC RHEUMATOLOGY	700 W Ironwood Dr, STE 275	Coeur d'Alene	ID	ToBeTerminated
DSH130049V	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC GENERAL SURGERY	700 W IRONWOOD DR STE 341	COEUR D ALENE	ID	ToBeTerminated
DSH130049W	Child	DSH	KOOTENAI HEALTH INC	KOOTENAI CLINIC INTERNAL MEDICINE	1919 LINCOLN WAY #110	COEUR D'ALENE	ID	ToBeTerminated
DSH130049X	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC INTERNAL MEDICINE	1701 LINCOLN WAY	COEUR D ALENE	ID	Terminated
DSH130049Y	Child	DSH	KOOTENAI HOSPITAL DISTRICT	KOOTENAI CLINIC INTERNAL MEDICINE	920 W IRONWOOD DR STE 201	COEUR D ALENE	ID	Terminated
DSH130049Z	Child	DSH	KOOTENAI MEDICAL CENTER	KOOTENAI CLINIC FAMILY MEDICINE	1300 E MULLAN AVE STE 1600	COEUR D ALENE	ID	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		7/1/2025 12:00:00 AM	4/28/2025 2:42 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	4/28/2025 2:42 PM
Terminations	Termination Date	Update	Hospital Type Change Request		7/1/2025 12:00:00 AM	4/28/2025 2:42 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		7/1/2025 12:00:00 AM	4/28/2025 2:42 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	4/28/2025 2:42 PM
Addresses	Shipping Address	Insert	Change Request		Kootenai Health Pharmacy Hayden 8882 N Government Way Suite L Hayden, ID 83835	4/17/2025 1:21 PM
Details	Last Recertification Date	Update	Recertification	8/17/2023 4:12:42 PM	8/20/2024 4:58:26 PM	8/20/2024 4:58 PM
Details	Entity Name	Update	Change Request	KOOTENAI HOSPITAL DISTRICT	KOOTENAI HEALTH INC	2/21/2024 11:16 AM
Details	Last Recertification Date	Update	Recertification	9/13/2022 3:53:05 PM	8/17/2023 4:12:42 PM	8/17/2023 4:12 PM
Contacts	Authorizing Official	Update	Change Request	Webb, Kim CFO Kootenai Health 2086254001	Bouit, Michele CFO Kootenai Health 2086254004	1/17/2023 6:59 AM
Details	Last Recertification Date	Update	Recertification	8/20/2021 4:46:57 PM	9/13/2022 3:53:05 PM	9/13/2022 3:53 PM
Details	Last Recertification Date	Update	Recertification		8/20/2021 4:46:57 PM	8/20/2021 4:46 PM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Addresses	Shipping Address	Insert	Change Request		Kootenai Health 2003 Kootenai Health Way Coeur d'Alene, ID 83814	6/29/2021 8:59 AM
Addresses	Shipping Address	Insert	Change Request		Kootenai Health Pharmacy 700 W Ironwood Drive 159 Coeur d'Alene, ID 83814	6/29/2021 8:59 AM
Addresses	Main Address	Update	Hospital Type Change Request	2003 Kootenai Health Way Coeur d'Alene, ID 83814	2003 KOOTENAI HEALTH WAY COEUR DALENE, ID 83814	6/22/2021 10:10 AM
Contacts	Signed By	Update	Hospital Type Change Request	Evans, Jeremy S. Vice President 2086254002	Webb, Kim CFO Kootenai Health 2086254001	6/22/2021 10:10 AM
Contacts	Primary Contact	Update	Hospital Type Change Request	Chapman, Timothy J. Pharmacy Business Manager Kootenai Health 2086255651	McDonald, Jim Pharmacy - 340B Program Manager Kootenai Health 2086255653	6/22/2021 10:10 AM
Details	Last Recertification Date	Update	Hospital Type Change Request	8/23/2018 5:01:55 PM		6/22/2021 10:10 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request	4/1/2019 12:00:00 AM		6/22/2021 10:10 AM
Dates	Participating Approval Date	Update	Hospital Type Change Request	9/10/2014 12:00:00 AM	6/22/2021 10:10:45 AM	6/22/2021 10:10 AM
Details	State	Update	Hospital Type Change Request	Terminated	Approved	6/22/2021 10:10 AM
Dates	Registration Date	Update	Hospital Type Change Request	7/11/2014 12:00:00 AM	6/16/2021 1:15:12 PM	6/22/2021 10:10 AM
Dates	Signed By Date	Update	Hospital Type Change Request	7/11/2014 12:00:00 AM	6/21/2021 5:57:08 PM	6/22/2021 10:10 AM
Dates	Start Date	Update	Hospital Type Change Request	10/1/2014 12:00:00 AM	7/1/2021 12:00:00 AM	6/22/2021 10:10 AM
Terminations	Termination Comments	Update	Hospital Type Change Request	We believe our DSH percentage will be going below 11.75 We are being proactive and will be going from DSH to RRC to avoid a lapse in coverage.		6/22/2021 10:10 AM
Terminations	Termination Date	Update	Hospital Type Change Request	4/1/2019 12:00:00 AM		6/22/2021 10:10 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request	4/1/2019 12:00:00 AM		6/22/2021 10:10 AM
Terminations	Termination Reason	Update	Hospital Type Change Request	DSH percentage below statutory minimum		6/22/2021 10:10 AM
Details	Comments Public	Insert	Hospital Type Change Request		Participating from effective date: (10/1/2014) until terminated effective date: (4/1/2019), reinstatement effective date: (06/22/21)	6/22/2021 6:52 AM
Details	State	Update		To Be Terminated	Terminated	4/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Edit Termination Info	1/10/2019 12:00:00 AM	4/1/2019 12:00:00 AM	1/11/2019 6:13 AM
Details	State	Update	OPA Edit Termination Info	Terminated	To Be Terminated	1/11/2019 6:13 AM
Terminations	Termination Date	Update	OPA Edit Termination Info	1/10/2019 12:00:00 AM	4/1/2019 12:00:00 AM	1/11/2019 6:13 AM
Terminations	Termination Effective Date	Update	OPA Edit Termination Info	1/10/2019 12:00:00 AM	4/1/2019 12:00:00 AM	1/11/2019 6:13 AM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Edit Termination Info	3/31/2019 12:00:00 AM	1/10/2019 12:00:00 AM	1/10/2019 3:13 PM
Details	State	Update	OPA Edit Termination Info	To Be Terminated	Terminated	1/10/2019 3:13 PM
Terminations	Termination Date	Update	OPA Edit Termination Info	4/1/2019 12:00:00 AM	1/10/2019 12:00:00 AM	1/10/2019 3:13 PM
Terminations	Termination Effective Date	Update	OPA Edit Termination Info	4/1/2019 12:00:00 AM	1/10/2019 12:00:00 AM	1/10/2019 3:13 PM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		3/31/2019 12:00:00 AM	1/9/2019 2:34 PM
Details	State	Update	Termination Request	Active	To Be Terminated	1/9/2019 2:34 PM
Terminations	Termination Comments	Update	Termination Request		We believe our DSH percentage will be going below 11.75 We are being proactive and will be going from DSH to RRC to avoid a lapse in coverage.	1/9/2019 2:34 PM
Terminations	Termination Date	Update	Termination Request		4/1/2019 12:00:00 AM	1/9/2019 2:34 PM
Terminations	Termination Effective Date	Update	Termination Request		4/1/2019 12:00:00 AM	1/9/2019 2:34 PM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	1/9/2019 2:34 PM
Details	Last Recertification Date	Update	Recertification	12/1/2017 3:07:57 PM	8/23/2018 5:01:55 PM	8/23/2018 5:01 PM
Contacts	Authorizing Official	Update	Change Request	Adams, John Controller Kootenai Health 2086254360	Webb, Kim CFO Kootenai Health 2086254001	4/27/2018 1:29 PM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	12/1/2017 3:07:57 PM	12/1/2017 3:07 PM
Contacts	Authorizing Official	Update		Adams, John Controller 2086254360	Adams, John Controller Kootenai Health 2086254360	9/21/2017 9:11 PM
Contacts	Primary Contact	Update		Chapman, Timothy J. Pharmacy Business Manager 2086255651	Chapman, Timothy J. Pharmacy Business Manager Kootenai Health 2086255651	9/20/2017 6:21 PM
Contacts	Authorizing Official	Insert			Adams, John Controller 2086254360	8/9/2017 11:54 AM
Contacts	Primary Contact	Update		Thorson, Dean 340b Business Manager 2086255651	Chapman, Timothy J. Pharmacy Business Manager 2086255651	7/28/2017 6:31 PM
Contacts	Signed By	Insert			Evans, Jeremy S. Vice President 2086254002	7/28/2017 6:31 PM
Addresses	Main Address	Insert			2003 Kootenai Health Way Coeur d'Alene, ID 83814	7/28/2017 6:31 PM
Details	Entity Name	Update		KOOTENAI MEDICAL CENTER	KOOTENAI HOSPITAL DISTRICT	6/30/2017 11:08 AM
Details	Entity Subname	Update			KOOTENAI HEALTH	6/30/2017 11:08 AM
Details	Last Recertification Date	Update		8/26/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 2:49 PM
Details	Last Recertification Date	Update			8/26/2015 12:00:00 AM	8/26/2015 3:14 PM
Contacts	Primary Contact	Insert			Thorson, Dean 340b Business Manager 2086255651	6/26/2015 9:40 AM
Dates	Participating Approval Date	Update			9/10/2014 12:00:00 AM	9/10/2014 11:03 AM
Details	State	Update		Pending	Active	9/10/2014 11:03 AM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	9/10/2014 11:03 AM
Details	340B ID	Update		ONLINE_REG_45216	DSH130049	9/9/2014 6:32 AM
Details	340B ID	Update			ONLINE_REG_45216	7/11/2014 8:58 AM
Details	Last Recertification Date	Insert				7/11/2014 8:57 AM
Details	Grant Number	Insert				7/11/2014 8:57 AM
Details	340B ID	Insert				7/11/2014 8:57 AM
Details	Is Authorizing Official EHB Data	Insert				7/11/2014 8:57 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/11/2014 8:57 AM
Details	Medicare Provider Number	Insert			130049	7/11/2014 8:57 AM
Details	Entity Name	Insert			KOOTENAI MEDICAL CENTER	7/11/2014 8:57 AM
Details	Program Code	Insert			DSH	7/11/2014 8:57 AM
Details	Entity Subname	Insert				7/11/2014 8:57 AM
Dates	Participating Approval Date	Insert				7/11/2014 8:57 AM
Details	State	Insert			Pending	7/11/2014 8:57 AM
Dates	Registration Date	Insert			7/11/2014 12:00:00 AM	7/11/2014 8:57 AM
Dates	Signed By Date	Insert			7/11/2014 12:00:00 AM	7/11/2014 8:57 AM
Dates	Start Date	Insert				7/11/2014 8:57 AM
Terminations	Termination Comments	Insert				7/11/2014 8:57 AM
Terminations	Termination Date	Insert				7/11/2014 8:57 AM
Terminations	Termination Effective Date	Insert				7/11/2014 8:57 AM
Terminations	Termination Reason	Insert				7/11/2014 8:57 AM