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SEMC MEDICAL VILLAGE PHARMACY
DSH180001 ST ELIZABETH FT THOMAS
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Covered Entity Details
Entity Name
ST ELIZABETH FT THOMAS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180001
Entity Address
85 NORTH GRAND AVENUE
FT. THOMAS, KY 41075-1793
Medicare Provider Number
180001
Participating Start Date
3/15/2022
Last Recertification Date
8/25/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
SEMC MEDICAL VILLAGE PHARMACY
Pharmacy Address
20 MEDICAL VILLAGE DR STE 101
EDGEWOOD, KY 41017
Pharmacy Comments
Contract Details
Approval Date
10/11/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/6/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Lori Ritchey-Baldwin, CFO
(859) 655-1642
Contract Pharmacy Representative
St. Elizabeth Healthcare
Angela Brunemann, Supervisor, Ambulatory Pharmacy
(859) 301-9025
Signed By Date
10/11/2018
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