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KOOTENAI CLINICS CANCER SERVICES
CAH131321-00 ST. MARYS HOSPITAL
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Covered Entity Details
Entity Name
ST. MARYS HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131321-00
Entity Address
701 LEWISTON ST.
COTTONWOOD, ID 83522-0137
Medicare Provider Number
131321
Participating Start Date
4/1/2019
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
KOOTENAI CLINICS CANCER SERVICES
Pharmacy Address
PHARMACY
700 W IRONWOOD DR STE 228
COEUR D ALENE, ID 83814
Pharmacy Comments
Contract Details
Approval Date
1/23/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/2/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jyl Ruland, CFO
(208) 476-8062
Contract Pharmacy Representative
Kootenai Health
Barbara Conti, Director of Ambulatory Pharmacy
(208) 625-5696
Signed By Date
1/23/2021
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