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KJK
CH041370 PERRY COUNTY MEDICAL CENTER, INC.
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Covered Entity Details
Entity Name
PERRY COUNTY MEDICAL CENTER, INC.
Subdivision Name
PERRY COUNTY MEDICAL CENTER, INC.
Type
HRSA-Funded Health Center
340B ID
CH041370
Entity Address
115 E BROOKLYN STREET
LINDEN, TN 37096
Grant Number
H80CS00346
Participating Start Date
4/1/2005
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
KJK
Pharmacy Address
DBA GOODLARK PHARMACY AT FAIRVIEW
2340 FAIRVIEW BLVD
STE 300
FAIRVIEW, TN 37062
Pharmacy Comments
Contract Details
Approval Date
1/2/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
PHILLIP TATUM, CEO
(931) 589-2104
Contract Pharmacy Representative
KJK D/B/A Goodlark Pharmacy at Fairview
John Kelsey, Main POC
(615) 387-9000
Signed By Date
1/2/2020
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