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AMBER PHARMACY
RRC130049-00 KOOTENAI HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
KOOTENAI HOSPITAL DISTRICT
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
4/1/2019
Last Recertification Date
8/18/2020
Entity Termination Date
7/1/2021
Pharmacy Details
Pharmacy Name
AMBER PHARMACY
Pharmacy Address
AMBER ENTERPRISES, INC.
10004 S 152ND STREET
SUITE A
OMAHA, NE 68138-3931
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
7/27/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kim Webb, CFO
(208) 625-4001
Contract Pharmacy Representative
Amber Pharmacy
Chris Combs, 340B Account Representative
(402) 680-0632
Signed By Date
1/15/2019
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