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WAL-MART PHARMACY 10-1743
FQHCLA362J 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 School Based Health at Harlan Independent Schools
Type
Health Center Program Look-Alike
340B ID
FQHCLA362J
Entity Address
420 E Central St
Harlan, KY 40831-2372
Grant Number
LALCS31536
Participating Start Date
7/1/2021
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1743
Pharmacy Address
201 WALTON ROAD
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
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/14/2024
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