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SAFEWAY INC
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
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #3295
1001 N FOURTH STREET
COEUR D ALENE, ID 83814-3113
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
4/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kim Webb, CFO
(208) 625-4001
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
1/15/2019
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