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K-VA-T FOOD STORES INC
FQHCLA362 Clover Fork Outpatient Medical Project, Inc.
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Covered Entity Details
Entity Name
Clover Fork Outpatient Medical Project, Inc.
Subdivision Name
Clover Fork Evarts
Type
Health Center Program Look-Alike
340B ID
FQHCLA362
Entity Address
101 Chad St
Evarts, KY 40828-8200
Grant Number
LALCS31536
Participating Start Date
4/1/2018
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
K-VA-T FOOD STORES INC
Pharmacy Address
FOOD CITY PHARMACY #437
2478 S US HIGHWAY 421
HARLAN, KY 40831
Pharmacy Comments
Contract Details
Approval Date
10/1/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jack Miniard, Chief Executive Officer
(606) 837-2108 Ext: 122
Contract Pharmacy Representative
KVAT Food Stores
Becky Blackstone, Pharmacy
(276) 623-5100 Ext: 5384
Signed By Date
10/1/2024
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