Yes
| KY | 31000045,54034913 | 1497195036,1376565226 |
Clover Fork Clinic Pharmacy
101 Chad Street
Evarts, KY 40828
| Contract Detail | KENTUCKY CVS PHARMACY, L.L.C. | DBA: CVS/PHARMACY # 06341 |
533 SKIDMORE DRIVE
| HARLAN | KY | 40831 | 10/14/2024 | 01/01/2025 | | | 01/01/2025 |
| FQHCLA362 | Active | BPS-LAL-021446 | Clover Fork Outpatient Medical Project, Inc. | Clover Fork Evarts | 101 Chad St | | Evarts | KY |
| FQHCLA362A | Active | BPS-LAL-021442 | Clover Fork Outpatient Medical Project, Inc. | Clover Fork Harlan | 209 E. Mound St. | | Harlan | KY |
| FQHCLA362B | Active | BPS-LAL-027642 | Clover Fork Outpatient Medical Project, Inc. | Clover Fork School Based Health at Verda Headstart | 54 School House Rd | | Evarts | KY |
| FQHCLA362C | Active | BPS-LAL-027648 | Clover Fork Outpatient Medical Project, Inc. | Clover Fork School Based Health at Black Mountain Elementary | 1555 Highway 215 | | Evarts | KY |
| FQHCLA362D | Active | BPS-LAL-027645 | Clover Fork Outpatient Medical Project, Inc. | Clover Fork School Based Health at Tri City Head Start | 119 Central St | | Cumberland | KY |
| FQHCLA362E | Active | BPS-LAL-027643 | Clover Fork Outpatient Medical Project, Inc. | Clover Fork School Based Health at Harlan County High School | 4000 N US Highway 119 | | Baxter | KY |
| FQHCLA362F | Active | BPS-LAL-027647 | Clover Fork Outpatient Medical Project, Inc. | Clover Fork School Based Health at Evarts Elementary | 132 Keister St | | Evarts | KY |
| FQHCLA362G | Active | BPS-LAL-027649 | Clover Fork Outpatient Medical Project, Inc. | Clover Fork School Based Health at Cumberland Elementary | 322 Golf Course Rd | | Cumberland | KY |
| FQHCLA362H | Active | BPS-LAL-027646 | Clover Fork Outpatient Medical Project, Inc. | Clover Fork School Based Health at Cawood Elementary | 51 Nola St | | Cawood | KY |
| FQHCLA362J | Active | BPS-LAL-031723 | Clover Fork Outpatient Medical Project, Inc. | Clover Fork School Based Health at Harlan Independent Schools | 420 E Central St | | Harlan | KY |
| FQHCLA362K | Active | BPS-LAL-038567 | CLOVER FORK OUTPATIENT MEDICAL PROJECT INC | Clover Fork Clinic Mobile Unit #1 | 101 Chad St | | Evarts | KY |
| FQHCLA362 | ADVANCED CARE SCRIPTS, INC | CVS/SPECIALTY OR CARELONRX SPECIALTY PHA |
6251 CHANCELLOR DRIVE
SUITE 101
| ORLANDO | FL | 32809 | 04/01/2024 | | |
| FQHCLA362 | CAREMARK FLORIDA SPECIALTY PHARMACY LLC | DBA CVS/SPECIALTY OR CARELONRX SPECIALTY |
7930 WOODLAND CENTER BLVD STE 500
| TAMPA | FL | 33614 | 04/01/2024 | | |
| FQHCLA362 | CAREMARK ILLINOIS SPECIALTY PHARMACY, LL | DBA CVS/SPECIALTY OR CARELONRX SPECIALTY |
800 BIERMANN CT STE B
| MOUNT PROSPECT | IL | 60056 | 04/01/2024 | | |
| FQHCLA362 | CAREMARK KANSAS SPECIALTY PHARMACY | CVS/SPECIALTY OR CARELONRX SPECIALTY PHA |
11162 RENNER BLVD
| LENEXA | KS | 66219 | 04/01/2024 | | |
| FQHCLA362 | CAREMARK MASSACHUSETTS SPECIALTY PHARMAC | DBA CVS/SPECIALTY OR CARELONRX SPECIALTY |
25 BIRCH STREET, BLDG B, SUITE 100
| MILFORD | MA | 01757 | 04/01/2024 | | |
| FQHCLA362 | CAREMARK MICHIGAN SPECIALTY PHARMACY, LL | DBA CVS/SPECIALTY OR CARELONRX SPECIALTY |
1307 ALLEN DR STE H
| TROY | MI | 48083 | 04/01/2024 | | |
| FQHCLA362 | CAREMARK NEW JERSEY SPECIALTY PHCY, LLC | DBA CVS/SPECIALTY OR CARELONRX SPECIALTY |
180 PASSAIC AVE UNIT B-5
| FAIRFIELD | NJ | 07004 | 04/01/2024 | | |
| FQHCLA362 | CAREMARK NORTH CAROLINA SPECIALTY PHARMA | DBA CVS/SPECIALTY OR CARELONRX SPECIALTY |
10700 WORLD TRADE BLVD STE 110
| RALEIGH | NC | 27617 | 04/01/2024 | | |
| FQHCLA362 | CAREMARK TENNESSEE SPECIALTY PHARMACY, L | DBA CVS/SPECIALTY OR CARELONRX SPECIALTY |
8370 WOLF LAKE DR
STE 107
| BARTLETT | TN | 38133 | 04/01/2024 | | |
| FQHCLA362 | CAREMARK, L.L.C. | DBA CVS/SPECIALTY OR CARELONRX SPECIALTY |
1127 BRYN MAWR AVE
SUITE A
| REDLANDS | CA | 92374 | 04/01/2024 | | |
| FQHCLA362 | CAREMARK, L.L.C. | DBA CVS/SPECIALTY OR CARELONRX SPECIALTY |
7251 S. EASTERN AVE.
| LAS VEGAS | NV | 89119 | 04/01/2024 | | |
| FQHCLA362 | CVS CAREMARK | DBA CVS/CAREMARK OR CF# 11506 |
1 GREAT VALLEY BOULEVARD
| WILKES BARRE | PA | 18706 | 04/01/2023 | | |
| FQHCLA362 | CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC | DBA CVS/CAREMARK 48067 |
1780 WALL ST
| MT PROSPECT | IL | 60056 | 04/01/2023 | | |
| FQHCLA362 | CVS/SPECIALTY OR CARELONRX SPECIALTY PHA | CAREMARK, LLC |
1001 SPINKS ROAD, STE 280
| FLOWER MOUND | TX | 75028 | 04/01/2024 | | |
| FQHCLA362 | K-VA-T FOOD STORES INC | FOOD CITY PHARMACY #437 |
2478 S US HIGHWAY 421
| HARLAN | KY | 40831 | 01/01/2025 | | |
| FQHCLA362F | K-VA-T FOOD STORES INC | FOOD CITY PHARMACY #437 |
2478 S US HIGHWAY 421
| HARLAN | KY | 40831 | 04/01/2025 | | |
| FQHCLA362 | KENTUCKY CVS PHARMACY, L.L.C. | DBA: CVS/PHARMACY # 06341 |
533 SKIDMORE DRIVE
| HARLAN | KY | 40831 | 04/01/2023 | | |
| FQHCLA362A | KENTUCKY CVS PHARMACY, L.L.C. | DBA: CVS/PHARMACY # 06341 |
533 SKIDMORE DRIVE
| HARLAN | KY | 40831 | 01/01/2025 | | |
| FQHCLA362 | OPTUM INFUSION SERVICES 305, LLC | 15529 COLLEGE BLVD. |
| LENEXA | KS | 66219-1351 | 10/01/2024 | | |
| FQHCLA362 | OPTUM INFUSION SERVICES 500 INC | 1893 GENERAL GEORGE PATTON DR |
# 100
| FRANKLIN | TN | 37067-2655 | 10/01/2024 | | 10/01/2024 |
| FQHCLA362 | OPTUM INFUSION SERVICES 550, LLC | 7167 E. KEMPER RD. |
| CINCINNATI | OH | 45249 | 10/01/2024 | | |
| FQHCLA362 | OPTUM PHARMACY 701, LLC | 4015 SHOPTON RD STE 600 |
| CHARLOTTE | NC | 28217-3025 | 10/01/2024 | | |
| FQHCLA362 | OPTUM PHARMACY 701, LLC | 1830 S HORNE |
| MESA | AZ | 85204 | 10/01/2024 | | |
| FQHCLA362 | OPTUM PHARMACY 702, LLC | 1050 PATROL RD |
| JEFFERSONVILLE | IN | 47130 | 10/01/2024 | | |
| FQHCLA362 | OPTUM PHARMACY 704, INC. | 5627 UNIVERSITY HTS STE 108 |
| SAN ANTONIO | TX | 78249 | 10/01/2024 | | |
| FQHCLA362 | OPTUMRX | OPTUMRX INC |
6800 W 115TH ST STE 600
| OVERLAND PARK | KS | 66211-9838 | 10/01/2024 | | |
| FQHCLA362 | PROCARE PHARMACY DIRECT, L.L.C. | DBA CVS/SPECIALTY OR CARELONRX SPECIALTY |
105 MALL BOULEVARD
| MONROEVILLE | PA | 15146 | 04/01/2024 | | |
| FQHCLA362 | PROCARE PHARMACY, L.L.C. | DBA: CVS/PHARMACY #2909 |
1521 4TH AVE., SOUTH
| BIRMINGHAM | AL | 35233 | 04/01/2024 | | |
| FQHCLA362 | PROCARE PHARMACY, L.L.C. | DBA CVS/PHARMACY #2923 |
3250 HARDEN ST. EXT. SUITE #300
| COLUMBIA | SC | 29203 | 04/01/2024 | | |
| FQHCLA362 | WAL-MART CENTRAL FILL 10-2670 | 608 SPRING HILL DR # 3 SUITE 300 |
| SPRING | TX | 77386 | 04/01/2023 | | |
| FQHCLA362 | WAL-MART PHARMACY 10-0742 | 2500 WEST STONE DRIVE |
| KINGSPORT | TN | 37660 | 04/01/2023 | | |
| FQHCLA362 | WAL-MART PHARMACY 10-1743 | 201 WALTON ROAD |
| HARLAN | KY | 40831 | 04/01/2023 | | |
| FQHCLA362J | WAL-MART PHARMACY 10-1743 | 201 WALTON ROAD |
| HARLAN | KY | 40831 | 01/01/2025 | | |
| FQHCLA362 | WAL-MART PHARMACY 10-5997 | 9600 PARKSOUTH CT. SUITE 100 |
| ORLANDO | FL | 32837 | 04/01/2023 | | |
| FQHCLA362 | WALMART PHARMACY 10-5169 | 2252 NORTH 8TH STREET |
SUITE A
| ROGERS | AR | 72756 | 04/01/2023 | | |
| FQHCLA362 | Walmart Pharmacy 10-7611 | 2501 Perry Rd |
| Plainfield | IN | 46168 | 01/01/2024 | | |
| Details | Last Recertification Date | Update | Recertification | 1/29/2024 8:06:55 AM | 2/10/2025 7:59:47 AM | 2/10/2025 7:59 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Blevins, Linda C
Office Manager
Clover Fork Outpatient Medical Project INC
6068372108-114 | Blevins, Linda C
Chief financial Officer
Clover Fork Outpatient Medical Project INC
6068372108-5114 | 2/4/2025 9:23 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Miniard, Jack
Chief Financial Officer
Clover Fork Outpatient Medical Project INC
6068372108-114 | Miniard, Jack
Chief Executive Officer
Clover Fork Outpatient Medical Project INC
6068372108-122 | 1/8/2025 12:20 PM |
| Contacts | Signed By | Update | Profile Change Request | Miniard, Jack
Chief Financial Officer
Clover Fork Outpatient Medical Project INC
6068372108-114 | Miniard, Jack
Chief Executive Officer
Clover Fork Outpatient Medical Project INC
6068372108-122 | 1/8/2025 12:20 PM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2023 8:27:45 AM | 1/29/2024 8:06:55 AM | 1/29/2024 8:06 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/16/2023 2:47 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 54034913 | 6/16/2023 2:47 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | KY | 6/16/2023 2:47 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1376565226 | 5/16/2023 8:54 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | KY | 5/16/2023 8:54 AM |
| Details | Last Recertification Date | Update | Recertification | 2/1/2022 4:43:26 PM | 1/30/2023 8:27:45 AM | 1/30/2023 8:27 AM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2021 11:50:00 AM | 2/1/2022 4:43:26 PM | 2/1/2022 4:43 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | KY | 2/3/2021 11:50 AM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2020 11:50:04 AM | 2/3/2021 11:50:00 AM | 2/3/2021 11:50 AM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2019 8:44:50 AM | 1/29/2020 11:50:04 AM | 1/29/2020 11:50 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 1/29/2019 8:44 AM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 31000045 | 1/29/2019 8:44 AM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | KY | 1/29/2019 8:44 AM |
| Medicaid Billing | NPI: Number | Update | Recertification | 1811939366 | 1497195036 | 1/29/2019 8:44 AM |
| Details | Last Recertification Date | Update | Recertification | | 1/29/2019 8:44:50 AM | 1/29/2019 8:44 AM |
| Addresses | Shipping Address | Insert | Change Request | | Clover Fork Clinic Pharmacy
101 Chad Street
Evarts, KY 40828 | 7/9/2018 9:45 AM |
| Details | Grant Number | Update | Change Request | LAL031536 | LALCS31536 | 7/9/2018 9:45 AM |
| Details | State | Update | | Approved | Active | 7/1/2018 12:00 AM |
| Contacts | Signed By | Insert | New Registration | | Miniard, Jack
Chief Financial Officer
Clover Fork Outpatient Medical Project INC
6068372108-114 | 4/10/2018 3:21 PM |
| Details | 340B ID | Update | New Registration | | FQHCLA362A | 4/10/2018 3:21 PM |
| Dates | Participating Approval Date | Update | New Registration | | 4/10/2018 3:21:06 PM | 4/10/2018 3:21 PM |
| Details | State | Update | New Registration | Pending | Approved | 4/10/2018 3:21 PM |
| Dates | Signed By Date | Update | New Registration | | 4/5/2018 10:46:07 AM | 4/10/2018 3:21 PM |
| Dates | Start Date | Update | New Registration | | 7/1/2018 12:00:00 AM | 4/10/2018 3:21 PM |
| Addresses | Main Address | Insert | New Registration | |
209 E. Mound St.
Harlan, KY 40831-2321 | 4/5/2018 10:07 AM |
| Addresses | Billing Address | Insert | New Registration | | Clover fork Clinic
PO Box 39
Evarts, KY 40828 | 4/5/2018 10:07 AM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1811939366 | 4/5/2018 10:07 AM |
| Contacts | Primary Contact | Insert | New Registration | | Blevins, Linda C
Office Manager
Clover Fork Outpatient Medical Project INC
6068372108-114 | 4/5/2018 10:07 AM |
| Contacts | Authorizing Official | Insert | New Registration | | Miniard, Jack
Chief Financial Officer
Clover Fork Outpatient Medical Project INC
6068372108-114 | 4/5/2018 10:07 AM |
| Details | Last Recertification Date | Insert | New Registration | | | 4/5/2018 10:07 AM |
| Details | Grant Number | Insert | New Registration | | LAL031536 | 4/5/2018 10:07 AM |
| Details | 340B ID | Insert | New Registration | | | 4/5/2018 10:07 AM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 4/5/2018 10:07 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 4/5/2018 10:07 AM |
| Details | Medicare Provider Number | Insert | New Registration | | | 4/5/2018 10:07 AM |
| Details | Entity Name | Insert | New Registration | | Clover Fork Outpatient Medical Project, Inc. | 4/5/2018 10:07 AM |
| Details | Program Code | Insert | New Registration | | FQHCLA | 4/5/2018 10:07 AM |
| Details | Entity Subname | Insert | New Registration | | Clover Fork Harlan | 4/5/2018 10:07 AM |
| Dates | Participating Approval Date | Insert | New Registration | | | 4/5/2018 10:07 AM |
| Details | State | Insert | New Registration | | Pending | 4/5/2018 10:07 AM |
| Dates | Registration Date | Insert | New Registration | | 4/5/2018 10:07:00 AM | 4/5/2018 10:07 AM |
| Dates | Signed By Date | Insert | New Registration | | | 4/5/2018 10:07 AM |
| Dates | Start Date | Insert | New Registration | | | 4/5/2018 10:07 AM |
| Terminations | Termination Comments | Insert | New Registration | | | 4/5/2018 10:07 AM |
| Terminations | Termination Date | Insert | New Registration | | | 4/5/2018 10:07 AM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 4/5/2018 10:07 AM |
| Terminations | Termination Reason | Insert | New Registration | | | 4/5/2018 10:07 AM |