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AETNA SPECIALTY PHARMACY, LLC
CAH181315-00 FORT LOGAN HOSPITAL
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Covered Entity Details
Entity Name
FORT LOGAN HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181315-00
Entity Address
110 METKER TRAIL
STANFORD, KY 40484
Medicare Provider Number
181315
Participating Start Date
9/16/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
AETNA SPECIALTY PHARMACY, LLC
Pharmacy Address
503 SUNPORT LN
ORLANDO, FL 32809-7874
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/18/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Ina Louise Glass, Administrator
(606) 365-4788
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/15/2019
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