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LAKE CUMBERLAND PHARMACY, LLC
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
LAKE CUMBERLAND PHARMACY, LLC
Pharmacy Address
LAKE CUMBERLAND PHARMACY
2431 LAKEWAY DR STE C
RUSSELL SPRINGS, KY 42642
Pharmacy Comments
Contract Details
Approval Date
10/4/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/25/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bud Wethington, CEO
(270) 651-4159
Contract Pharmacy Representative
Russell County Hospital
Jonathan Grider, Managing Member
(270) 858-6400
Signed By Date
10/4/2016
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