Contract Pharmacy Details

KENTUCKY CVS PHARMACY, L.L.C.
FQHCLA362A Clover Fork Outpatient Medical Project, Inc.

Covered Entity Details

Entity Name

Clover Fork Outpatient Medical Project, Inc.

Subdivision Name

Clover Fork Harlan

Type

Health Center Program Look-Alike

340B ID

FQHCLA362A

Entity Address

209 E. Mound St.
Harlan, KY 40831-2321

Grant Number

LALCS31536

Participating Start Date

7/1/2018

Last Recertification Date

2/10/2025

Pharmacy Details

Pharmacy Name

KENTUCKY CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 06341
533 SKIDMORE DRIVE
HARLAN, KY 40831

Pharmacy Comments

Contract Details

Approval Date

10/14/2024

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

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

10/14/2024

340B Drug Pricing Program Database