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KROGER PHARMACY #464
DSH250167 METHODIST H/C OLIVE BRANCH HOSPT
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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 PHARMACY #464
Pharmacy Address
3095 GOODMAN ROAD
SOUTHAVEN, MS 38672
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
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