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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 #3350
600 NORTH MAIN STREET
MUNFORDVILLE, KY 42765
Pharmacy Comments
Contract Details
Approval Date
4/5/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/19/2018
Ownership change
Contacts
Covered Entity Signing Official
Bud Wethington, CEO
(270) 651-4159
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
4/5/2017
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