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WAL-MART PHARMACY 10-3472
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
WAL-MART PHARMACY 10-3472
Pharmacy Address
3050 EAST MULLAN AVENUE
POST FALLS, ID 83854
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
7/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kim Webb, CFO
(208) 625-4001
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
6/29/2021
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