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SOUTH CREEK DRUG
DSH180020 MIDDLESBORO ARH HOSPITAL
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Covered Entity Details
Entity Name
MIDDLESBORO ARH HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180020
Entity Address
3600 WEST CUMBERLAND AVE
MIDDLESBORO, KY 40965
Medicare Provider Number
180020
Participating Start Date
4/1/2005
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
10/27/2020
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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