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K-VA-T FOOD STORES INC
DSH180020 MIDDLESBORO ARH HOSPITAL
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Covered Entity Details
Entity Name
MIDDLESBORO ARH HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180020
Entity Address
3600 WEST CUMBERLAND AVE
MIDDLESBORO, KY 40965
Medicare Provider Number
180020
Participating Start Date
4/1/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
K-VA-T FOOD STORES INC
Pharmacy Address
FOOD CITY PHARMACY #437
2478 S US HIGHWAY 421
HARLAN, KY 40831
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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