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MEDICINE MAN BONNERS FERRY PHARMACY
CAH131301-00 BOUNDARY COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
BOUNDARY COMMUNITY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131301-00
Entity Address
6640 KANIKSU
BONNERS FERRY, ID 83805
Medicare Provider Number
131301
Participating Start Date
1/1/2023
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
MEDICINE MAN BONNERS FERRY PHARMACY
Pharmacy Address
6452 MAIN STREET
BONNERS FERRY, ID 83805
Pharmacy Comments
Contract Details
Approval Date
10/15/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
CRAIG JOHNSON, CEO
(208) 267-4850
Contract Pharmacy Representative
Aimee Stuermer, Owner
(208) 267-4024
Signed By Date
10/15/2015
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