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BAPTIST HEALTH OUTPATIENT PHARMACY
DSH180138 Baptist Health Lagrange
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Covered Entity Details
Entity Name
Baptist Health Lagrange
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180138
Entity Address
1025 New Moody Lane
La Grange, KY 40031
Medicare Provider Number
180138
Participating Start Date
7/1/2013
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
BAPTIST HEALTH OUTPATIENT PHARMACY
Pharmacy Address
1 Trillium Way
Corbin, KY 40701
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/4/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Clint Kaho, President
(502) 222-3329
Contract Pharmacy Representative
Baptist Health Corbin
Anthony Powers, COO
(606) 523-8626
Signed By Date
1/15/2019
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