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SEMC MEDICAL VILLAGE PHARMACY
DSH180045 ST. ELIZABETH FLORENCE
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Covered Entity Details
Entity Name
ST. ELIZABETH FLORENCE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180045
Entity Address
4900 HOUSTON ROAD
FLORENCE, KY 41042-4824
Medicare Provider Number
180045
Participating Start Date
10/1/2016
Last Recertification Date
9/2/2019
Entity Termination Date
10/1/2020
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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