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AVELLA OF SACRAMENTO, 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
AVELLA OF SACRAMENTO, INC.
Pharmacy Address
2288 AUBURN BLVD #102
SACRAMENTO, CA 95821
Pharmacy Comments
01/28/2013 name update (was GREATER SACRAMENTO PHARMACY, INC.)
Contract Details
Approval Date
4/6/2018
Contract Begin Date
7/1/2018
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
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
4/6/2018
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