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KROGER PHARMACY #774
DSH510038 STONEWALL JACKSON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
STONEWALL JACKSON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510038
Entity Address
230 Hospital Plaza
WESTON, WV 26452
Medicare Provider Number
510038
Participating Start Date
1/1/2019
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #774
Pharmacy Address
102 EMILY DR
CLARKSBURG, WV 26301-5501
Pharmacy Comments
Contract Details
Approval Date
10/8/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/24/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kevin Stalnaker, Chief Administrative Officer
(304) 269-8152
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/8/2018
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