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KROGER DRUGSTORE #393
DSH110023 AdventHealth Gordon
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Covered Entity Details
Entity Name
AdventHealth Gordon
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110023
Entity Address
1035 RED BUD ROAD NE
CALHOUN, GA 30701
Medicare Provider Number
110023
Participating Start Date
4/1/2008
Last Recertification Date
9/6/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
KROGER DRUGSTORE #393
Pharmacy Address
136 WEST BELMONT DRIVE, SW
CALHOUN, GA 30701
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/14/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Cory David Reeves, CFO
(706) 879-4710
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
4/15/2019
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