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SALEM CLINIC PHARMACY
STD42078 Tri-Rivers Healthcare, PLLC
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Covered Entity Details
Entity Name
Tri-Rivers Healthcare, PLLC
Subdivision Name
Salem Medical Clinic
Type
Sexually Transmitted Diseases
340B ID
STD42078
Entity Address
141 Hospital Dr
Salem, KY 42078
Grant Number
NH25PS005135
Participating Start Date
1/1/2024
Last Recertification Date
5/8/2025
Pharmacy Details
Pharmacy Name
SALEM CLINIC PHARMACY
Pharmacy Address
141 HOSPITAL DR
PO BOX 498
SALEM, KY 42078-0498
Pharmacy Comments
Contract Details
Approval Date
11/3/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael A Heneisen, Business Manager
(270) 988-3298
Contract Pharmacy Representative
Salem Clinic Pharmacy
Michael Keller, President
(270) 988-3230
Signed By Date
10/11/2023
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