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RIVERSIDE PHARMACY
DSH180013 THE MEDICAL CENTER - BOWLING GREEN
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Covered Entity Details
Entity Name
THE MEDICAL CENTER - BOWLING GREEN
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180013
Entity Address
250 PARK STREET
BOWLING GREEN, KY 42101
Medicare Provider Number
180013
Participating Start Date
4/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
RIVERSIDE PHARMACY
Pharmacy Address
825 SECOND AVENUE EAST
SUITE A1
BOWLING GREEN, KY 42101
Pharmacy Comments
Contract Details
Approval Date
7/11/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Wade R. Stone, Executive Vice President
(270) 745-1504
Contract Pharmacy Representative
Commonwealth Health Corporation
Caleb Benningfield, Pharmacist
(270) 745-1640
Signed By Date
7/11/2023
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