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JACKS PHARMACY INC
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
JACKS PHARMACY INC
Pharmacy Address
103 E COLLEGE AVE
ST MARIES, ID 83861
Pharmacy Comments
Contract Details
Approval Date
4/4/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Baker, CEO
(208) 292-0256
Contract Pharmacy Representative
Jack's Pharmacy
Benjamin Potter, CEO
(208) 758-4183
Signed By Date
4/4/2024
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