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KENTUCKY CVS PHARMACY, L.L.C.
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
KENTUCKY CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #10155
102 VILLAGE LANE
HAZARD, KY 41701
Pharmacy Comments
Contract Details
Approval Date
7/7/2020
Contract Begin Date
7/9/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joseph Grossman, PRESIDENT and CEO
(859) 226-2450
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/7/2020
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