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OPTUM PHARMACY 702, LLC
RRC130049-00 KOOTENAI HEALTH INC
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Covered Entity Details
Entity Name
KOOTENAI HEALTH INC
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
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
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
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/14/2025
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