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WAL-MART PHARMACY 10-3362
CHC26595-02 PENNYROYAL HEALTHCARE SERVICES INC.
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Covered Entity Details
Entity Name
PENNYROYAL HEALTHCARE SERVICES INC.
Subdivision Name
Community Medical Clinic, Oak Grove
Type
HRSA-Funded Health Center
340B ID
CHC26595-02
Entity Address
244 Thompsonville Lane
OAK GROVE, KY 42262-9301
Grant Number
H80CS26595
Participating Start Date
4/1/2016
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3362
Pharmacy Address
14800 FT. CAMBELL BLVD
OAK GROVE, KY 42262
Pharmacy Comments
Contract Details
Approval Date
10/9/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Agreement registered in error
Contacts
Covered Entity Signing Official
Kecia Fulcher, CEO
(270) 365-0227
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/9/2017
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