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KENTUCKY CVS PHARMACY, L.L.C.
CH045064C Kentucky Mountain Health Alliance, Inc.
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Covered Entity Details
Entity Name
Kentucky Mountain Health Alliance, Inc.
Subdivision Name
Quantum Healthcare Associates, Inc.
Type
HRSA-Funded Health Center
340B ID
CH045064C
Entity Address
210 Black Gold Blvd
Hazard, KY 41701-2603
Grant Number
H80CS07772
Participating Start Date
10/1/2023
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
KENTUCKY CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #10155
102 VILLAGE LANE
HAZARD, KY 41701
Pharmacy Comments
Contract Details
Approval Date
10/6/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ELLEN JEAN VANCE, EXECUTIVE DIRECTOR
(606) 487-9505 Ext: 7
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/6/2024
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