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MEDICINE MAN BONNERS FERRY PHARMACY
DSH130049 KOOTENAI HEALTH INC
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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
MEDICINE MAN BONNERS FERRY PHARMACY
Pharmacy Address
6452 MAIN ST
BONNERS FERRY, ID 83805-8520
Pharmacy Comments
Contract Details
Approval Date
4/7/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joan Simon, Chief Nursing Officer
(208) 625-4002
Contract Pharmacy Representative
Aimee Stuermer, Owner
(208) 267-4024
Signed By Date
4/7/2015
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