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MEDICINE MAN NORTH PHARMACY
DSH130049 KOOTENAI HEALTH INC
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Covered Entity Details
Entity Name
KOOTENAI HEALTH INC
Subdivision Name
KOOTENAI HEALTH
Type
Disproportionate Share Hospital
340B ID
DSH130049
Entity Address
2003 Kootenai Health Way
COEUR DALENE, ID 83814
Medicare Provider Number
130049
Participating Start Date
7/1/2021
Last Recertification Date
8/20/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
MEDICINE MAN NORTH PHARMACY
Pharmacy Address
INC DBA MEDICINE MAN PRAIRIE
8093 N CORNERSTONE DR
HAYDEN, ID 83835-8753
Pharmacy Comments
Contract Details
Approval Date
6/29/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2022
Ownership change
Contacts
Covered Entity Signing Official
Kim Webb, CFO
(208) 625-4001
Contract Pharmacy Representative
Medicine Man Prairie
Barry Feely, Owner
(208) 762-9355
Signed By Date
6/29/2021
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