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MEDICINE MAN NORTH PHCY INC
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
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
MEDICINE MAN NORTH PHCY INC
Pharmacy Address
DBA MEDICINE MAN HAYDEN PHCY
240 W HAYDEN AVE
PO BOX 1706
HAYDEN, ID 83835
Pharmacy Comments
Contract Details
Approval Date
1/5/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John Adams, Controller
(208) 625-4360
Contract Pharmacy Representative
Medicine Man North Pharmacy Inc.
Barry Feely, Owner
(208) 762-9337
Signed By Date
1/5/2016
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