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MEDICAL ARTS PHARMACY
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
MEDICAL ARTS PHARMACY
Pharmacy Address
1220 N RACE ST
GLASGOW, KY 42141-3462
Pharmacy Comments
Contract Details
Approval Date
4/11/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bud Wethington, CEO
(270) 651-4159
Contract Pharmacy Representative
William Gravely, Pharmacist Manager
(270) 651-7030
Signed By Date
4/11/2017
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