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FOOD CITY PHARMACY #458
CAH181305-00 ARH OUR LADY OF THE WAY
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Covered Entity Details
Entity Name
ARH OUR LADY OF THE WAY
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181305-00
Entity Address
11203 MAIN STREET
MARTIN, KY 41649
Medicare Provider Number
181305
Participating Start Date
9/24/2010
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
FOOD CITY PHARMACY #458
Pharmacy Address
215 CASSIDY BLVD
PO BOX 4027
PIKEVILLE, KY 41501
Pharmacy Comments
Contract Details
Approval Date
7/7/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joseph Grossman, PRESIDENT and CEO
(859) 226-2450
Contract Pharmacy Representative
K-VA-T Food Stores, Inc
Mickey Blazer, Pharmacy Director
(423) 247-1961
Signed By Date
7/7/2020
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