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KROGER PHARMACY
CH0514720 RAPHAEL HEALTH CENTER, Inc.
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Covered Entity Details
Entity Name
RAPHAEL HEALTH CENTER, Inc.
Subdivision Name
RAPHAEL HEALTH CENTER, Inc.
Type
HRSA-Funded Health Center
340B ID
CH0514720
Entity Address
401 E 34th St
Indianapolis, IN 46205-3754
Grant Number
H80CS00266
Participating Start Date
7/1/2004
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
KROGER PHARMACY
Pharmacy Address
#116
680 TWIN AIRE DRIVE
INDIANAPOLIS, IN 46203
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
1/10/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sherry Gray, Chief Executive Officer
(317) 860-3962
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
4/15/2019
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