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WALGREEN 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
WALGREEN CO.
Pharmacy Address
WALGREENS #17438
394 N DIXIE ST
HORSE CAVE, KY 42749
Pharmacy Comments
Contract Details
Approval Date
1/24/2018
Contract Begin Date
1/24/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/24/2025
Pharmacy closed
Contacts
Covered Entity Signing Official
Bud Wethington, CEO
(270) 651-4159
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/24/2018
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