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BANDY'S LTC LLC
RRC140046-00 GOOD SAMARITAN REGIONAL HEALTH CTR.
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Covered Entity Details
Entity Name
GOOD SAMARITAN REGIONAL HEALTH CTR.
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140046-00
Entity Address
1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864
Medicare Provider Number
140046
Participating Start Date
10/1/2015
Last Recertification Date
9/14/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
BANDY'S LTC LLC
Pharmacy Address
DBA BANDY'S LONG TERM CARE PHARMACY
1415 W WHITTAKER ST
SALEM, IL 62881-2015
Pharmacy Comments
Contract Details
Approval Date
10/14/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jeremy Shawn Bradford, President
(618) 899-1002
Contract Pharmacy Representative
Bandy's
Eric Bandy, CFO
(618) 548-4000
Signed By Date
10/14/2021
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