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JEFF'S PRESCRIPTION SHOP
DSH180012 Baptist Health Hardin
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Covered Entity Details
Entity Name
Baptist Health Hardin
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180012
Entity Address
913 NORTH DIXIE AVENUE
ELIZABETHTOWN, KY 42701
Medicare Provider Number
180012
Participating Start Date
4/1/2017
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
JEFF'S PRESCRIPTION SHOP
Pharmacy Address
2415 RING ROAD
ELIZABETHTOWN, KY 42701
Pharmacy Comments
Contract Details
Approval Date
10/3/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Thomas Carrico, Chief Operating Officer
(270) 706-5321
Contract Pharmacy Representative
LJB Inc.
Charles Bradley Mills, Owner/Pharmacist
(270) 765-2157
Signed By Date
10/3/2017
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