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WALMART PHARMACY 10-5169
FQHCLA362 Clover Fork Outpatient Medical Project, Inc.
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Covered Entity Details
Entity Name
Clover Fork Outpatient Medical Project, Inc.
Subdivision Name
Clover Fork Evarts
Type
Health Center Program Look-Alike
340B ID
FQHCLA362
Entity Address
101 Chad St
Evarts, KY 40828-8200
Grant Number
LALCS31536
Participating Start Date
4/1/2018
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jack Miniard, Chief Executive Officer
(606) 837-2108 Ext: 122
Contract Pharmacy Representative
Wellpartner
Michael Petryna, National Sales Executive
(720) 377-7745
Signed By Date
1/17/2023
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