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KROGER SPECIALTY PHARMACY TX
DSH320021 PRESBYTERIAN HOSPITAL
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Covered Entity Details
Entity Name
PRESBYTERIAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320021
Entity Address
1100 CENTRAL AVENUE SE
ALBUQUERQUE, NM 87106
Medicare Provider Number
320021
Participating Start Date
4/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
KROGER SPECIALTY PHARMACY TX
Pharmacy Address
4280 KELLWAY CIR
ADDISON, TX 75001-4200
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/9/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sandra C. Podley, VP Operations PDS
(505) 923-5364
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/15/2019
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