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CYSTIC FIBROSIS SERVICES, LLC
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
4/1/2019
Last Recertification Date
8/18/2020
Entity Termination Date
7/1/2021
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/14/2025
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