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MEDICINE MAN NORTH PHARMACY
CH108170 Dirne Health Centers, Inc.
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Covered Entity Details
Entity Name
Dirne Health Centers, Inc.
Subdivision Name
Heritage Health CDA
Type
HRSA-Funded Health Center
340B ID
CH108170
Entity Address
1090 W Park Pl
Coeur D Alene, ID 83814-2785
Grant Number
H80CS02331
Participating Start Date
4/1/2004
Last Recertification Date
3/5/2025
Pharmacy Details
Pharmacy Name
MEDICINE MAN NORTH PHARMACY
Pharmacy Address
MEDICINE MAN NORTH PHARMACY
305 W KATHLEEN AVE
COEUR D ALENE, ID 83815
Pharmacy Comments
Contract Details
Approval Date
12/28/2022
Contract Begin Date
12/28/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Baker, CEO
(208) 292-0256
Contract Pharmacy Representative
Medicine Man North Pharmacy Inc
Korey Kreider, Pharmacy Owner
(208) 762-9355
Signed By Date
12/28/2022
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