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KROGER PHARMACY #579
DSH450723 METHODIST CHARLTON MEDICAL CENTER
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Covered Entity Details
Entity Name
METHODIST CHARLTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450723
Entity Address
3500 WEST WHEATLAND ROAD
DALLAS, TX 75237-3460
Medicare Provider Number
450723
Participating Start Date
7/1/2005
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #579
Pharmacy Address
500 MARKETPLACE BLVD
FORNEY, TX 75126
Pharmacy Comments
Contract Details
Approval Date
7/9/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/7/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jon T Albrecht, Corporate VP, Chief Pharmacy Officer
(214) 947-2504
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/9/2019
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