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ALBERTSON'S LLC
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
ALBERTSON'S LLC
Pharmacy Address
SAFEWAY PHARMACY #265
6520 N NEVADA ST
SPOKANE, WA 99208
Pharmacy Comments
Contract Details
Approval Date
7/13/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Adams, Controller
(208) 625-4360
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
7/13/2016
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