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JACKS PHARMACY INC
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
Pharmacy Details
Pharmacy Name
JACKS PHARMACY INC
Pharmacy Address
103 E COLLEGE AVE
ST MARIES, ID 83861
Pharmacy Comments
Contract Details
Approval Date
6/29/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kim Webb, CFO
(208) 625-4001
Contract Pharmacy Representative
Jack's Pharmacy
Benjamin Potter, CEO
(208) 758-4183
Signed By Date
6/29/2021
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