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LAKE CUMBERLAND PHARMACY, LLC
DSH180154 PINEVILLE COMMUNITY HEALTH CENTER, Inc.
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Covered Entity Details
Entity Name
PINEVILLE COMMUNITY HEALTH CENTER, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180154
Entity Address
850 RIVERVIEW AVENUE
PINEVILLE, KY 40977
Medicare Provider Number
180154
Participating Start Date
7/26/2021
Last Recertification Date
9/9/2024
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
7/28/2021
Contract Begin Date
8/2/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Terry Wayne Nichols, CEO
(660) 633-7305
Contract Pharmacy Representative
Russell County Hospital
Jonathan Grider, Managing Member
(270) 858-6400
Signed By Date
7/28/2021
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