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FAMILY PHARMACY ROGERSVILLE
FQHCLA219 FORDLAND CLINIC INC
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Covered Entity Details
Entity Name
FORDLAND CLINIC INC
Subdivision Name
Type
Health Center Program Look-Alike
340B ID
FQHCLA219
Entity Address
1059 BARTON DRIVE
FORDLAND, MO 65652
Grant Number
LALCS00078
Participating Start Date
7/1/2007
Last Recertification Date
2/10/2015
Entity Termination Date
4/1/2016
Pharmacy Details
Pharmacy Name
FAMILY PHARMACY ROGERSVILLE
Pharmacy Address
FAMILY PHARMACY #5
432 S MILLST
PO BOX 515
ROGERSVILLE, MO 65742
Pharmacy Comments
Contract Details
Approval Date
5/7/2008
Contract Begin Date
5/7/2008
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
5/7/2008
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