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SHOPKO PHARMACY #2069
RRC130049-00 KOOTENAI HEALTH INC
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Covered Entity Details
Entity Name
KOOTENAI HEALTH INC
Subdivision Name
Type
Rural Referral Center
340B ID
RRC130049-00
Entity Address
2003 KOOTENAI HEALTH WAY
COEUR DALENE, ID 83814
Medicare Provider Number
130049
Participating Start Date
7/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2069
Pharmacy Address
217 WEST IRONWOOD DRIVE
COEUR D'ALENE, ID 83814
Pharmacy Comments
Contract Details
Approval Date
2/1/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/6/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Kim Webb, CFO
(208) 625-4001
Contract Pharmacy Representative
Shopko Pharmacy
Debi Danbury, 340B Program Manager
(920) 429-7613
Signed By Date
1/15/2019
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