Contract Pharmacy Details

KROGER FOOD & PHARMACY #452
DSH250167 METHODIST H/C OLIVE BRANCH HOSPT

Covered Entity Details

Entity Name

METHODIST H/C OLIVE BRANCH HOSPT

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH250167

Entity Address

4250 BETHEL ROAD
OLIVE BRANCH, MS 38654

Medicare Provider Number

250167

Participating Start Date

4/1/2019

Last Recertification Date

9/4/2024

Pharmacy Details

Pharmacy Name

KROGER FOOD & PHARMACY #452

Pharmacy Address

7427 GOODMAN RD
OLIVE BRANCH, MS 38654

Pharmacy Comments

Contract Details

Approval Date

7/10/2019

Contract Begin Date

10/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/18/2024
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Chuck Lane, SVP/Associate CFO
(901) 516-0549

Contract Pharmacy Representative

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

Signed By Date

7/10/2019

340B Drug Pricing Program Database