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WAL-MART PHARMACY 10-3511
RRC130049-00 KOOTENAI HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
KOOTENAI HOSPITAL DISTRICT
Subdivision Name
Type
Rural Referral Center
340B ID
RRC130049-00
Entity Address
2003 KOOTENAI HEALTH WAY
COEUR DALENE, ID 83814
Medicare Provider Number
130049
Participating Start Date
7/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3511
Pharmacy Address
550 W. HONEYSUCKLE AVE.
HAYDEN, ID 83835
Pharmacy Comments
Contract Details
Approval Date
4/28/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michele Bouit, CFO
(208) 625-4004
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
4/14/2025
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