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WAL-MART PHARMACY 10-2654
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
WAL-MART PHARMACY 10-2654
Pharmacy Address
1650 EDMONTON ROAD
TOMPKINSVILLE, KY 42167
Pharmacy Comments
Contract Details
Approval Date
4/4/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bud Wethington, CEO
(270) 651-4159
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/4/2017
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