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KB PHARMACY, LLC
STD420811 Tri-Rivers Healthcare, PLLC
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Covered Entity Details
Entity Name
Tri-Rivers Healthcare, PLLC
Subdivision Name
Smithland Medical Clinic
Type
Sexually Transmitted Diseases
340B ID
STD420811
Entity Address
205 E Adair Street
Smithland, KY 42081
Grant Number
NH25PS005135
Participating Start Date
1/1/2024
Last Recertification Date
5/9/2024
Pharmacy Details
Pharmacy Name
KB PHARMACY, LLC
Pharmacy Address
320 S MAIN ST
PO BOX 437
MARION, KY 42064-1545
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
KB Pharmacy LLC
Bradley Boone, Co-Owner/Pharmacist
(270) 967-9007
Signed By Date
10/11/2023
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