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FOOD CITY PHARMACY #458
DSH180005 HIGHLANDS ARH REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
HIGHLANDS ARH REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180005
Entity Address
5000 KY RT 321
PRESTONSBURG, KY 41653
Medicare Provider Number
180005
Participating Start Date
9/9/2005
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
Contract Termination Date
Termination Reason
4/4/2022
Business decision by covered entity and/or pharmacy
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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