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KROGER PHARMACY #765
DSH360133 Kettering Health Dayton
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Covered Entity Details
Entity Name
Kettering Health Dayton
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360133
Entity Address
405 W. Grand Avenue
Dayton, OH 45405
Medicare Provider Number
360133
Participating Start Date
7/1/2013
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #765
Pharmacy Address
601 WOODMAN DR
DAYTON, OH 45431
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
10/21/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael David Mewhirter, VP of Finance, CFO
(937) 723-3414
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/15/2019
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