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ASCENSION RX 1401
CAH011305-01 St. Vincent's Blount
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Covered Entity Details
Entity Name
St. Vincent's Blount
Subdivision Name
ST. VINCENT'S PRIMARY CARE - ONEONT - Primary Care Clinic
Type
Critical Access Hospital
340B ID
CAH011305-01
Entity Address
150 GILBREATH DR
ONEONTA, AL 35121-2827
Medicare Provider Number
011305
Outpatient Facility Provider Number
Participating Start Date
1/1/2019
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
ASCENSION RX 1401
Pharmacy Address
150 GILBREATH DR STE 104
ONEONTA, AL 35121
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/16/2021
Agreement registered in error
Contacts
Covered Entity Signing Official
Gregory Dale Brown, Administrator
(205) 274-3010
Contract Pharmacy Representative
Pharmacy
stacey L Hill, Director
(205) 274-3310
Signed By Date
7/14/2020
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