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RITE AID OF KENTUCKY, INC.
DSH180017 TJ SAMSON COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
TJ SAMSON COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180017
Entity Address
1301 NORTH RACE STREET
GLASGOW, KY 42141
Medicare Provider Number
180017
Participating Start Date
7/1/2005
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
RITE AID OF KENTUCKY, INC.
Pharmacy Address
RITE AID #4006
704 HAPPY VALLEY ROAD
GLASGOW, KY 42141
Pharmacy Comments
Contract Details
Approval Date
4/17/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/19/2018
Ownership change
Contacts
Covered Entity Signing Official
Neil Thornbury, CEO
(270) 651-4159
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
4/17/2014
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