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LAKE CUMBERLAND PHARMACY, LLC
CAH181309-00 CASEY COUNTY HOSPITAL DISTRICT D/B/A CASEY COUNTY HOSPITAL
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Covered Entity Details
Entity Name
CASEY COUNTY HOSPITAL DISTRICT D/B/A CASEY COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181309-00
Entity Address
187 WOLFORD AVENUE
LIBERTY, KY 42539
Medicare Provider Number
181309
Participating Start Date
7/1/2011
Last Recertification Date
9/3/2024
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
4/20/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
REX A. TUNGATE, CEO
(606) 787-6275 Ext: 601
Contract Pharmacy Representative
Russell County Hospital
Jonathan Grider, Managing Member
(270) 858-6400
Signed By Date
4/20/2016
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