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ASCENSION RX 1401
CAH011305-00 St. Vincent's Blount
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Covered Entity Details
Entity Name
St. Vincent's Blount
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH011305-00
Entity Address
150 Gilbreath Drive
Oneonta, AL 35121
Medicare Provider Number
011305
Participating Start Date
1/1/2014
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
1/14/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/29/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gregory Dale Brown, Administrator
(205) 274-3010
Contract Pharmacy Representative
St. Vincents Blount
Gavin Keith Gilliland, Director of Pharmacy
(205) 274-3337
Signed By Date
1/14/2021
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