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MEDICINE MAN NORTH PHARMACY
CH10817J DIRNE HEALTH CENTERS, INC.
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Covered Entity Details
Entity Name
DIRNE HEALTH CENTERS, INC.
Subdivision Name
Dirne CHC Physical Therapy
Type
HRSA-Funded Health Center
340B ID
CH10817J
Entity Address
610 W Hubbard St
Coeur D Alene, ID 83814-2285
Grant Number
H80CS02331
Participating Start Date
1/1/2015
Last Recertification Date
2/12/2015
Entity Termination Date
1/1/2016
Pharmacy Details
Pharmacy Name
MEDICINE MAN NORTH PHARMACY
Pharmacy Address
305 W KATHLEEN AVE
COEUR D ALENE, ID 83815
Pharmacy Comments
Contract Details
Approval Date
10/23/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2016
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Medicine Man North Pharmacy Inc.
Barry Feely, Owner
(208) 762-9337
Signed By Date
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