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WAL-MART PHARMACY 10-3472
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
WAL-MART PHARMACY 10-3472
Pharmacy Address
3050 EAST MULLAN AVENUE
POST FALLS, ID 83854
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
7/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kim Webb, CFO
(208) 625-4001
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/15/2019
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