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TOMPKINSVILLE DRUG CO
DSH180017 TJ SAMSON COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
TJ SAMSON COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180017
Entity Address
1301 NORTH RACE STREET
GLASGOW, KY 42141
Medicare Provider Number
180017
Participating Start Date
7/1/2005
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
TOMPKINSVILLE DRUG CO
Pharmacy Address
1513 EDMONTON RD
TOMPKINSVILLE, KY 42167-9402
Pharmacy Comments
Contract Details
Approval Date
1/11/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/15/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bud Wethington, CEO
(270) 651-4159
Contract Pharmacy Representative
TOMPKINSVILLE DRUG CO
J P Nixon, Pharmacist in Charge
(270) 487-6155
Signed By Date
1/11/2018
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