340B Drug Pricing Program Database
Home
Search
Search Covered Entities
Search Contract Pharmacies
Search Manufacturers
Reports
Help
Login
MEDICINE MAN ATHOL PHARMACY
DSH130049 KOOTENAI HEALTH INC
Print
Covered Entity Details
Entity Name
KOOTENAI HEALTH INC
Subdivision Name
KOOTENAI HEALTH
Type
Disproportionate Share Hospital
340B ID
DSH130049
Entity Address
2003 Kootenai Health Way
COEUR DALENE, ID 83814
Medicare Provider Number
130049
Participating Start Date
7/1/2021
Last Recertification Date
8/20/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
MEDICINE MAN ATHOL PHARMACY
Pharmacy Address
30585 N ROBERTS RD
ATHOL, ID 83801
Pharmacy Comments
Contract Details
Approval Date
7/19/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kim Webb, CFO
(208) 625-4001
Contract Pharmacy Representative
Medicine Man North Pharmacy Inc.
Barry Feely, Owner
(208) 762-9337
Signed By Date
7/19/2018
Continue Your Session
For security reasons inactive sessions are automatically closed.
Your session will be closed shortly if you don't continue it.
Continue Your Session