Covered Entity Details

DSH180017G TJ SAMSON COMMUNITY HOSPITAL (Active) - information as of 5/23/2025 12:16:07 AM

Main Details

Name

TJ SAMSON COMMUNITY HOSPITAL

Subdivision Name

TJHP Primary Care Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH180017G

Medicare Provider Number

180017

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/10/2015

Participating Start Date

4/1/2015

Participating Approval Date

2/26/2015

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

TJ Regional Health
Neil Thornbury, CEO
(270) 651-4159

Primary Contact

TJ Regional Health
John Thomas Rogers, Compliance Officer
(270) 651-4513

Addresses

Street Address

310N L ROGERS WELLS BLVD
GLASGOW, KY 42141-1300

Billing Address

TJ Samson Community Hospital
1301 NORTH RACE STREET
GLASGOW, KY 42141

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
KY	7100261550,7100261530,01011956	1770581894,1477609865

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH180017A	Child	DSH	T.J. SAMSON COMMUNITY HOSPITAL	Cave City Clinic	400N DIXIE HWY	CAVE CITY	KY	Terminated
DSH180017AA	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	T J Samson Specialty Services - Psychiatry Clinic - Psychiatry Clinic	1337C N Race St	Glasgow	KY	Active
DSH180017AB	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	ENT CLINIC - ENT	310 N. L Rogers Wells Blvd.	Glasgow	KY	Active
DSH180017B	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	Pain Management Clinic	310N L ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017C	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	Cardiology Clinic	310N L ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017D	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	TJHP Nephrology Clinic	310N L ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017E	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	Urology Clinic	310N L ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017F	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	Pulmonary Critical Care	310N L ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017G	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	TJHP Primary Care Clinic	310N L ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017H	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	TJHP General Surgery	310N L ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017J	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	Women's Health	310N L ROGERS WELLS BLVD	GLASGOW	KY	Terminated
DSH180017K	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	OB/GYN	310N L ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017L	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	TJHP Oncology	310N L ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017M	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	Clinic - Urgent Care	310N L ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017N	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	Family Practice Clinic (Resident Clinic)	1325 NORTH RACE STREET	GLASGOW	KY	Active
DSH180017P	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	TJ HEALTH CAVE CITY	440 E HAPPY VALLEY ST	CAVE CITY	KY	Active
DSH180017Q	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	TOMPKINSVILLE CLINIC - TOMPKINSVILLE CLINIC	800 N. Main Street	Tompkinsville	KY	Terminated
DSH180017R	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	GI CLINIC - GI CLINIC	310 N. L. ROGERS WELLS BLVD	Glasgow	KY	Active
DSH180017S	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	NEURO SURGERY - NEURO SURGERY	310 N. L. ROGERS WELLS BLVD	Glasgow	KY	Active
DSH180017T	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	RENAL DIALYSIS - RENAL DIALYSIS	310 N. L. ROGERS WELLS BLVD	GLASGOW	KY	Terminated
DSH180017U	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	RADIOLOGY-DIAGNOSTIC - RADIOLOGY-DIAGNOSTIC	310 N. L. ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017V	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	MAGNETIC RESONANCE IMAGING (MRI) - MAGNETIC RESONANCE IMAGING (MRI)	310 N. L. ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017W	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	CT SCAN - CT SCAN	310 N. L. ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017X	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	INTRAVENOUS THERAPY - PAV IV THERAPY	310 N. L. ROGERS WELLS BLVD	GLASGOW	KY	Active
DSH180017Y	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	T.J. SPECIALTY SERVICES - DERMATOLOGY CLINIC	1337 C North Race Street	Glasgow	KY	Terminated
DSH180017Z	Child	DSH	TJ SAMSON COMMUNITY HOSPITAL	Orthopedic Clinic - Orthopedics	106 Columns Plaza Drive	Glasgow	KY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/17/2023 11:10:57 AM	8/15/2024 10:02:47 AM	8/15/2024 10:02 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 11:48:52 AM	8/17/2023 11:10:57 AM	8/17/2023 11:10 AM
Details	Last Recertification Date	Update	Recertification	8/30/2021 3:27:25 PM	9/8/2022 11:48:52 AM	9/8/2022 11:48 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 12:12:40 PM	8/30/2021 3:27:25 PM	8/30/2021 3:27 PM
Medicaid Billing	NPI: State	Update	Recertification		KY	9/8/2020 12:12 PM
Medicaid Billing	NPI: State	Update	Recertification		KY	9/8/2020 12:12 PM
Details	Last Recertification Date	Update	Recertification	9/3/2019 11:25:31 AM	9/8/2020 12:12:40 PM	9/8/2020 12:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/23/2020 10:31 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7100261550	3/23/2020 10:31 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	3/23/2020 10:31 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/23/2020 10:31 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7100261530	3/23/2020 10:31 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	3/23/2020 10:31 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477609865	3/23/2020 10:31 AM
Details	Last Recertification Date	Update	Recertification	8/29/2018 2:23:00 PM	9/3/2019 11:25:31 AM	9/3/2019 11:25 AM
Contacts	Authorizing Official	Update	Profile Change Request	Thornbury, Neil CEO TJ Samson Community Hospital 2706514159	Thornbury, Neil CEO TJ Regional Health 2706514159	1/10/2019 3:22 PM
Contacts	Signed By	Update	Profile Change Request	Thornbury, Neil CEO TJ Samson Community Hospital 2706514159	Thornbury, Neil CEO TJ Regional Health 2706514159	1/10/2019 3:22 PM
Contacts	Primary Contact	Update	Profile Change Request	Rogers, John Thomas 340B Program Coordinator TJ Samson Community Hospital 2706514513	Rogers, John Thomas Compliance Officer TJ Regional Health 2706514513	1/7/2019 11:16 AM
Addresses	Billing Address	Insert	Recertification		TJ Samson Community Hospital 1301 NORTH RACE STREET GLASGOW, KY 42141	8/29/2018 2:23 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 5:25:29 PM	8/29/2018 2:23:00 PM	8/29/2018 2:23 PM
Contacts	Authorizing Official	Update	Profile Change Request	Thornbury, Neil COO TJ Samson Community Hospital 2706595643	Thornbury, Neil CEO TJ Samson Community Hospital 2706514159	6/1/2018 2:38 PM
Contacts	Signed By	Update	Profile Change Request	Thornbury, Neil COO TJ Samson Community Hospital 2706595643	Thornbury, Neil CEO TJ Samson Community Hospital 2706514159	6/1/2018 2:38 PM
Contacts	Authorizing Official	Update	Change Request	Wethington, Bud CEO TJ Samson Community Hospital 2706514159	Thornbury, Neil COO TJ Samson Community Hospital 2706595643	5/18/2018 1:47 PM
Contacts	Signed By	Update		Thornbury, Neil COO 2706595643	Thornbury, Neil COO TJ Samson Community Hospital 2706595643	5/16/2018 9:45 AM
Contacts	Primary Contact	Update	Recertification	Wethington, Bud CEO TJ Samson Community Hospital 2706514159	Rogers, John Thomas 340B Program Coordinator TJ Samson Community Hospital 2706514513	12/4/2017 5:25 PM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	12/4/2017 5:25:29 PM	12/4/2017 5:25 PM
Details	Entity Name	Update	Recertification	T.J. SAMSON COMMUNITY HOSPITAL	TJ SAMSON COMMUNITY HOSPITAL	12/4/2017 5:09 PM
Contacts	Authorizing Official	Update		Wethington, Bud CEO 2706514159	Wethington, Bud CEO TJ Samson Community Hospital 2706514159	10/17/2017 12:52 PM
Contacts	Primary Contact	Update		Wethington, Bud CEO 2706514159	Wethington, Bud CEO TJ Samson Community Hospital 2706514159	10/17/2017 12:52 PM
Contacts	Authorizing Official	Insert			Wethington, Bud CEO 2706514159	6/15/2017 12:49 PM
Contacts	Primary Contact	Update		Adams, Kevin Director of Pharmacy 2706514334	Wethington, Bud CEO 2706514159	6/15/2017 12:49 PM
Contacts	Signed By	Insert			Thornbury, Neil COO 2706595643	4/28/2017 6:07 PM
Addresses	Main Address	Insert			310N L ROGERS WELLS BLVD GLASGOW, KY 42141-1300	4/28/2017 6:07 PM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/12/2016 12:00:00 AM	8/12/2016 9:48 AM
Contacts	Primary Contact	Insert			Adams, Kevin Director of Pharmacy 2706514334	8/6/2015 8:24 AM
Details	Last Recertification Date	Update			8/6/2015 12:00:00 AM	8/6/2015 8:22 AM
Dates	Participating Approval Date	Update			2/26/2015 12:00:00 AM	2/26/2015 6:38 PM
Details	State	Update		Pending	Active	2/26/2015 6:38 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	2/26/2015 6:38 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_48589	DSH180017G	2/11/2015 3:31 PM
Details	Entity Subname	Update		TJ SAMSON COMMUNITY HOSPITAL / TJHP Primary Care Clinic	TJHP Primary Care Clinic	2/11/2015 3:31 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_48589	1/10/2015 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/10/2015 11:12 AM
Medicaid Billing	Medicaid: Number	Insert			01011956	1/10/2015 11:12 AM
Medicaid Billing	Medicaid: State	Insert			KY	1/10/2015 11:12 AM
Medicaid Billing	NPI: Number	Insert			1770581894	1/10/2015 11:12 AM
Details	Last Recertification Date	Insert				1/10/2015 11:12 AM
Details	Grant Number	Insert				1/10/2015 11:12 AM
Details	340B ID	Insert				1/10/2015 11:12 AM
Details	Is Authorizing Official EHB Data	Insert				1/10/2015 11:12 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/10/2015 11:12 AM
Details	Medicare Provider Number	Insert			180017	1/10/2015 11:12 AM
Details	Entity Name	Insert			T.J. SAMSON COMMUNITY HOSPITAL	1/10/2015 11:12 AM
Details	Program Code	Insert			DSH	1/10/2015 11:12 AM
Details	Entity Subname	Insert			TJ SAMSON COMMUNITY HOSPITAL / TJHP Primary Care Clinic	1/10/2015 11:12 AM
Dates	Participating Approval Date	Insert				1/10/2015 11:12 AM
Details	State	Insert			Pending	1/10/2015 11:12 AM
Dates	Registration Date	Insert			1/10/2015 12:00:00 AM	1/10/2015 11:12 AM
Dates	Signed By Date	Insert			1/10/2015 12:00:00 AM	1/10/2015 11:12 AM
Dates	Start Date	Insert				1/10/2015 11:12 AM
Terminations	Termination Comments	Insert				1/10/2015 11:12 AM
Terminations	Termination Date	Insert				1/10/2015 11:12 AM
Terminations	Termination Effective Date	Insert				1/10/2015 11:12 AM
Terminations	Termination Reason	Insert				1/10/2015 11:12 AM