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EAST HICKMAN PHARMACY
CH04137A PERRY COUNTY MEDICAL CENTER INC
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Covered Entity Details
Entity Name
PERRY COUNTY MEDICAL CENTER INC
Subdivision Name
THREE RIVERS COMMUNITY HLTH GRP-HICKMAN
Type
HRSA-Funded Health Center
340B ID
CH04137A
Entity Address
7723 Clearview Church Ln STE 100
Lyles, TN 37098-1609
Grant Number
H80CS00346
Participating Start Date
1/1/2008
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
EAST HICKMAN PHARMACY
Pharmacy Address
7723 CLEARVIEW CHURCH LN
LYLES, TN 37098-1674
Pharmacy Comments
Contract Details
Approval Date
3/3/2023
Contract Begin Date
3/6/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
PHILLIP TATUM, CEO
(931) 589-2104
Contract Pharmacy Representative
KJK D/B/A Goodlark Pharmacy at Fairview
John Kelsey, Main POC
(615) 387-9000
Signed By Date
3/3/2023
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