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K-VA-T FOOD STORES INC
DSH180050 HARLAN ARH HOSPITAL
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Covered Entity Details
Entity Name
HARLAN ARH HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180050
Entity Address
81 BALL PARK ROAD
HARLAN, KY 40831
Medicare Provider Number
180050
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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