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FAMILY PHARMACY #4
FQHCLA219A FORDLAND CLINIC
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Covered Entity Details
Entity Name
FORDLAND CLINIC
Subdivision Name
Tri Lakes Community Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA219A
Entity Address
11863 State Hwy 13
Kimberling City, MO 65686-0555
Grant Number
LALCS00078
Participating Start Date
10/1/2015
Last Recertification Date
Entity Termination Date
4/1/2016
Pharmacy Details
Pharmacy Name
FAMILY PHARMACY #4
Pharmacy Address
18192 BUSINESS 13 STE A
PO BOX 2043
BRANSON WEST, MO 65737
Pharmacy Comments
Contract Details
Approval Date
7/31/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Robert Marsh, Exec. Director
(417) 767-2273 Ext: 2021
Contract Pharmacy Representative
Carrie Tennis, Director of Operations
(417) 581-4335
Signed By Date
7/31/2015
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