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GENOA HEALTHCARE LLC
FQHCLA396A SHAWNEE MENTAL HEALTH CENTER INC
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Covered Entity Details
Entity Name
SHAWNEE MENTAL HEALTH CENTER INC
Subdivision Name
Coal Grove Clinic
Type
Health Center Program Look-Alike
340B ID
FQHCLA396A
Entity Address
225 Carlton Davidson Ln
Coal Grove, OH 45638-2924
Grant Number
LALCS32583
Participating Start Date
10/1/2019
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
GENOA HEALTHCARE LLC
Pharmacy Address
225 CARLTON DAVIDSON LN RM 1
COAL GROVE, OH 45638
Pharmacy Comments
Contract Details
Approval Date
1/9/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Cynthia Holstein, CEO
(740) 442-7670
Contract Pharmacy Representative
GENOA HEALTHCARE LLC
William Guptail, COO
(479) 739-1973
Signed By Date
1/9/2024
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