Contract Pharmacy Details

INTERLAKE PHARMACY
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

Entity Termination Date

7/1/2025

Pharmacy Details

Pharmacy Name

INTERLAKE PHARMACY

Pharmacy Address

700 W IRONWOOD DR STE 159
COEUR D ALENE, ID 83814-4401

Pharmacy Comments

Contract Details

Approval Date

4/10/2015

Contract Begin Date

7/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Joan Simon, Chief Nursing Officer
(208) 625-4002

Contract Pharmacy Representative

Dean Thorson, Pharmacy Admin
(208) 625-5651

Signed By Date

4/10/2015