Contract Pharmacy Details

RITE AID OF KENTUCKY, INC.
DSH180017 TJ SAMSON COMMUNITY HOSPITAL

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 #3272
612 WEST STOCKTON STREET
EDMONTON, KY 42129

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

340B Drug Pricing Program Database