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KENTUCKY CVS PHARMACY, L.L.C.
DSH180043 AdventHealth Manchester
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Covered Entity Details
Entity Name
AdventHealth Manchester
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180043
Entity Address
210 MARIE LANGDON DRIVE
MANCHESTER, KY 40962
Medicare Provider Number
180043
Participating Start Date
10/1/2017
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
KENTUCKY CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06342
2104 NORTH MAIN ST
LONDON, KY 40741
Pharmacy Comments
Contract Details
Approval Date
10/8/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel Camacho, CFO
(606) 598-1035
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/8/2021
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