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SOUTH CREEK DRUG
DSH180005 HIGHLANDS ARH REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
HIGHLANDS ARH REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180005
Entity Address
5000 KY RT 321
PRESTONSBURG, KY 41653
Medicare Provider Number
180005
Participating Start Date
9/9/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
SOUTH CREEK DRUG
Pharmacy Address
130 WALMART PLAZA DR UNIT 1
MONTICELLO, KY 42633-7943
Pharmacy Comments
Contract Details
Approval Date
10/15/2020
Contract Begin Date
10/27/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/16/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joseph Grossman, PRESIDENT and CEO
(859) 226-2450
Contract Pharmacy Representative
London Valu-Rite Pharmacy, Inc
Timothy Carnes, Manager
(270) 566-1074
Signed By Date
10/15/2020
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