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KMART 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
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
KMART PHARMACY
Pharmacy Address
4110 E SPRAGUE AVENUE
SPOKANE, WA 99202
Pharmacy Comments
Contract Details
Approval Date
4/13/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/12/2017
Pharmacy closed
Contacts
Covered Entity Signing Official
John Adams, Controller
(208) 625-4360
Contract Pharmacy Representative
Jennifer Speares, Director of Administration/Compliance
(847) 286-5116
Signed By Date
4/13/2016
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