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KROGER PHARMACY #687
DSH040119 WHITE RIVER MEDICAL CENTER
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Covered Entity Details
Entity Name
WHITE RIVER MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040119
Entity Address
1710 HARRISON STREET
BATESVILLE, AR 72501
Medicare Provider Number
040119
Participating Start Date
7/1/2009
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #687
Pharmacy Address
303 S SAINT LOUIS ST
BATESVILLE, AR 72501-3555
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jana Richardson, Controller
(870) 262-3222
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
4/15/2019
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