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MEDICINE MAN ATHOL PHARMACY
CH108170 Dirne Health Centers, Inc.
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Covered Entity Details
Entity Name
Dirne Health Centers, Inc.
Subdivision Name
Heritage Health CDA
Type
HRSA-Funded Health Center
340B ID
CH108170
Entity Address
1090 W Park Pl
Coeur D Alene, ID 83814-2785
Grant Number
H80CS02331
Participating Start Date
4/1/2004
Last Recertification Date
3/5/2025
Pharmacy Details
Pharmacy Name
MEDICINE MAN ATHOL PHARMACY
Pharmacy Address
30585 N ROBERTS RD
ATHOL, ID 83801
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/28/2022
Ownership change
Contacts
Covered Entity Signing Official
Michael Baker, CEO
(208) 292-0256
Contract Pharmacy Representative
Medicine Man Athol Pharmacy
Barry Feely, Main POC
(208) 699-9337
Signed By Date
10/15/2018
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