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DAVIS FOOD AND DRUG # 1
TB84078 Tricounty Health Department
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Covered Entity Details
Entity Name
Tricounty Health Department
Subdivision Name
Type
Tuberculosis
340B ID
TB84078
Entity Address
133 South 500 East
Vernal, UT 84078
Grant Number
NU52PS910197-03
Participating Start Date
10/1/2017
Last Recertification Date
5/13/2024
Pharmacy Details
Pharmacy Name
DAVIS FOOD AND DRUG # 1
Pharmacy Address
575 W MAIN ST
VERNAL, UT 84078-2405
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jordan D. Mathis, Local Health Officer/Executive Director
(435) 247-1172
Contract Pharmacy Representative
Davis Food and Drug
Mike Sorenson, Pharmacist
(435) 789-2001
Signed By Date
4/16/2018
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