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LOCUST FORK PHARMACY LLC
CAH011305-00 St. Vincent's Blount
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Covered Entity Details
Entity Name
St. Vincent's Blount
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH011305-00
Entity Address
150 Gilbreath Drive
Oneonta, AL 35121
Medicare Provider Number
011305
Participating Start Date
1/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
LOCUST FORK PHARMACY LLC
Pharmacy Address
LOCUST FORK PHARMACY
29984 STATE HIGHWAY 79 STE 600
LOCUST FORK, AL 35097-5879
Pharmacy Comments
Contract Details
Approval Date
1/8/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/8/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Evan Ray, President
(205) 274-3010
Contract Pharmacy Representative
Johnny Cleveland, Pharmacist
(205) 680-2222
Signed By Date
1/8/2015
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