Contract Pharmacy Details

WALGREEN CO.
DSH130049 KOOTENAI HEALTH INC

Covered Entity Details

Entity Name

KOOTENAI HEALTH INC

Subdivision Name

KOOTENAI HEALTH

Type

Disproportionate Share Hospital

340B ID

DSH130049

Entity Address

2003 Kootenai Health Way
COEUR DALENE, ID 83814

Medicare Provider Number

130049

Participating Start Date

7/1/2021

Last Recertification Date

8/20/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #07846
2702 N. ARGONNE RD.
MILLWOOD, WA 99212

Pharmacy Comments

Contract Details

Approval Date

10/3/2014

Contract Begin Date

10/6/2014

Carve-In Effective Date

Contract Comments

10/06/2014 Immediate Begin Date authorized

Contract Termination Date
Termination Reason

4/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Jeremy S. Evans, Vice President
(208) 625-4002

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

10/3/2014

340B Drug Pricing Program Database