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BLAKE PHARMACY
FQHCLA396 SHAWNEE MENTAL HEALTH CENTER INC
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Covered Entity Details
Entity Name
SHAWNEE MENTAL HEALTH CENTER INC
Subdivision Name
Portsmouth Clinic
Type
Health Center Program Look-Alike
340B ID
FQHCLA396
Entity Address
901 Washington St
Portsmouth, OH 45662-3944
Grant Number
LALCS32583
Participating Start Date
10/1/2019
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
BLAKE PHARMACY
Pharmacy Address
206 N MARKET ST
WEST UNION, OH 45693
Pharmacy Comments
Contract Details
Approval Date
1/6/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/9/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Cynthia Holstein, CEO
(740) 442-7670
Contract Pharmacy Representative
Blake Pharmacy
Katie Sheeley, Pharmacist
(937) 587-3100
Signed By Date
1/6/2022
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