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KOHAL PHARMACY INCORPORATED
CAH131314-00 SHOSHONE MEDICAL CENTER
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Covered Entity Details
Entity Name
SHOSHONE MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131314-00
Entity Address
25 jacobs Gulch
KELLOGG, ID 83837
Medicare Provider Number
131314
Participating Start Date
10/1/2018
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
KOHAL PHARMACY INCORPORATED
Pharmacy Address
KOHAL PHARMACY, INC.
740 MCKINLEY AVE
KELLOGG, ID 83837-2693
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jerry Brantz, CEO/CFO
(208) 784-7017
Contract Pharmacy Representative
Kohal Pharmacy
Tony Wright, Owner
(208) 786-9303
Signed By Date
1/14/2019
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