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STANFORD DRUG
CAH181315-00 FORT LOGAN HOSPITAL
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Covered Entity Details
Entity Name
FORT LOGAN HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181315-00
Entity Address
110 METKER TRAIL
STANFORD, KY 40484
Medicare Provider Number
181315
Participating Start Date
9/16/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
STANFORD DRUG
Pharmacy Address
107 METKER TRL STE D
PO BOX 364
STANFORD, KY 40484-1049
Pharmacy Comments
Contract Details
Approval Date
1/10/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/3/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MIKE JACKSON, CEO
(606) 365-4771
Contract Pharmacy Representative
Rendall Kilbourne, President
(606) 365-2100
Signed By Date
1/10/2014
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