Covered Entity Details

FQHCLA362C Clover Fork Outpatient Medical Project, Inc. (Active) - information as of 4/25/2025 6:29:37 PM

Main Details

Name

Clover Fork Outpatient Medical Project, Inc.

Subdivision Name

Clover Fork School Based Health at Black Mountain Elementary

Type

Health Center Program Look-Alike

Site ID

BPS-LAL-027648

340B ID

FQHCLA362C

Grant Number

LALCS31536

Additional Details

Current Program Status

Active

Registration Date

10/1/2019

Participating Start Date

1/1/2020

Participating Approval Date

10/7/2019

Last Recertification Date

2/10/2025

Contacts

Authorizing Official

Clover Fork Outpatient Medical Project INC
Jack Miniard, Chief Executive Officer
(606) 837-2108 Ext: 122

Primary Contact

Clover Fork Outpatient Medical Project INC
Linda C Blevins, Chief financial Officer
(606) 837-2108 Ext: 5114

Addresses

Street Address

1555 Highway 215
Evarts, KY 40828-6522

Billing Address

Clover Fork Outpatient Medical Project INC.
101 Chad Street
Box 39
Evarts, KY 40828

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
KY	54034913,31000045	1811939366,1376565226

Shipping Addresses

Shipping Address 1

Clover Fork Outpatient Medical Project INC.
101 Chad Street
Box 39
Evarts, KY 40828

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
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

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
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

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	1/29/2024 8:07:44 AM	2/10/2025 8:05:30 AM	2/10/2025 8:05 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 8:24:35 AM	1/29/2024 8:07:44 AM	1/29/2024 8:07 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/16/2023 2:50 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		31000045	6/16/2023 2:50 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	6/16/2023 2:50 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1376565226	5/8/2023 10:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		KY	5/8/2023 10:04 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1376565226 (KY)		5/8/2023 8:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1811939366	5/8/2023 8:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		KY	5/8/2023 8:57 AM
Details	Last Recertification Date	Update	Recertification	2/1/2022 4:45:29 PM	1/30/2023 8:24:35 AM	1/30/2023 8:24 AM
Details	Last Recertification Date	Update	Recertification	2/3/2021 11:42:53 AM	2/1/2022 4:45:29 PM	2/1/2022 4:45 PM
Medicaid Billing	NPI: State	Update	Recertification		KY	2/3/2021 11:42 AM
Details	Last Recertification Date	Update	Recertification	1/29/2020 12:01:27 PM	2/3/2021 11:42:53 AM	2/3/2021 11:42 AM
Details	Last Recertification Date	Update	Recertification		1/29/2020 12:01:27 PM	1/29/2020 12:01 PM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		Miniard, Jack Chief Financial Officer Clover Fork Outpatient Medical Project INC 6068372108-114	10/7/2019 11:15 AM
Details	340B ID	Update	New Registration		FQHCLA362C	10/7/2019 11:15 AM
Dates	Participating Approval Date	Update	New Registration		10/7/2019 11:15:25 AM	10/7/2019 11:15 AM
Details	State	Update	New Registration	Pending	Approved	10/7/2019 11:15 AM
Dates	Signed By Date	Update	New Registration		10/1/2019 9:56:25 AM	10/7/2019 11:15 AM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	10/7/2019 11:15 AM
Addresses	Main Address	Insert	New Registration		1555 Highway 215 Evarts, KY 40828-6522	10/1/2019 9:56 AM
Addresses	Billing Address	Insert	New Registration		Clover Fork Outpatient Medical Project INC. 101 Chad Street Box 39 Evarts, KY 40828	10/1/2019 9:56 AM
Addresses	Shipping Address	Insert	New Registration		Clover Fork Outpatient Medical Project INC. 101 Chad Street Box 39 Evarts, KY 40828	10/1/2019 9:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/1/2019 9:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		54034913	10/1/2019 9:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	10/1/2019 9:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1376565226	10/1/2019 9:56 AM
Contacts	Primary Contact	Insert	New Registration		Blevins, Linda C Office Manager Clover Fork Outpatient Medical Project INC 6068372108-114	10/1/2019 9:56 AM
Contacts	Authorizing Official	Insert	New Registration		Miniard, Jack Chief Financial Officer Clover Fork Outpatient Medical Project INC 6068372108-114	10/1/2019 9:56 AM
Details	Last Recertification Date	Insert	New Registration			10/1/2019 9:56 AM
Details	Grant Number	Insert	New Registration		LALCS31536	10/1/2019 9:56 AM
Details	340B ID	Insert	New Registration			10/1/2019 9:56 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/1/2019 9:56 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/1/2019 9:56 AM
Details	Medicare Provider Number	Insert	New Registration			10/1/2019 9:56 AM
Details	Entity Name	Insert	New Registration		Clover Fork Outpatient Medical Project, Inc.	10/1/2019 9:56 AM
Details	Program Code	Insert	New Registration		FQHCLA	10/1/2019 9:56 AM
Details	Entity Subname	Insert	New Registration		Clover Fork School Based Health at Black Mountain Elementary	10/1/2019 9:56 AM
Dates	Participating Approval Date	Insert	New Registration			10/1/2019 9:56 AM
Details	State	Insert	New Registration		Pending	10/1/2019 9:56 AM
Dates	Registration Date	Insert	New Registration		10/1/2019 9:56:23 AM	10/1/2019 9:56 AM
Dates	Signed By Date	Insert	New Registration			10/1/2019 9:56 AM
Dates	Start Date	Insert	New Registration			10/1/2019 9:56 AM
Terminations	Termination Comments	Insert	New Registration			10/1/2019 9:56 AM
Terminations	Termination Date	Insert	New Registration			10/1/2019 9:56 AM
Terminations	Termination Effective Date	Insert	New Registration			10/1/2019 9:56 AM
Terminations	Termination Reason	Insert	New Registration			10/1/2019 9:56 AM

340B Drug Pricing Program Database