Contract Pharmacy Details

KOHAL PHARMACY INC
DSH130049 KOOTENAI HEALTH INC

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

KOHAL PHARMACY INC

Pharmacy Address

KOHAL PHARMACY INC
800 BANK ST
WALLACE, ID 83873

Pharmacy Comments

Contract Details

Approval Date

4/11/2023

Contract Begin Date

5/10/2023

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/26/2024
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Michele Bouit, CFO
(208) 625-4004

Contract Pharmacy Representative

Kohal Pharmacy
Tony Wright, Owner
(208) 786-9303

Signed By Date

4/11/2023