Contract Pharmacy Details

KROGER PHARMACY #534
DSH190111 WILLIS KNIGHTON MEDICAL CENTER, INC.

Covered Entity Details

Entity Name

WILLIS KNIGHTON MEDICAL CENTER, INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH190111

Entity Address

2600 GREENWOOD ROAD
SHREVEPORT, LA 71103

Medicare Provider Number

190111

Participating Start Date

1/1/2007

Last Recertification Date

8/17/2024

Pharmacy Details

Pharmacy Name

KROGER PHARMACY #534

Pharmacy Address

1050 GEORGE DEMENT BLVD
BOSSIER CITY, LA 71111

Pharmacy Comments

Contract Details

Approval Date

4/8/2019

Contract Begin Date

7/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/10/2025
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Mary Jane Ward, Senior Vice President - CFO
(318) 212-4384

Contract Pharmacy Representative

Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875

Signed By Date

4/8/2019

340B Drug Pricing Program Database